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� Cit of Orono ►�" � ���� <br /> y � ��,�I� <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �'� Mailing Address: Permit number. 020/3 -DO�' '�'/ � <br /> ,�� ���/� � PO Box 66 <br /> � '�. Crystal Bay, MN 55323-0066 �ate received: S-ZI- / 'J <br /> f� t <br /> I: � � Street Address: Received by: �S <br /> , .; �- J <br /> � � � 2750 Kelley Parkway Plan review fee: � ��� G�— <br /> `' f� -Y� ��� Orono, MN 55356 <br /> \?KFsf���,lt,% aoi�3-do3 90 <br /> _. - Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �� � �R' �(� � <br /> Will this be a Parade of Homes, Remodelers Sho case me or other Display Home? ❑ Yes No <br /> /f yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shutt/e bus rvice will be <br /> required unless applicanf demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Lead Certification Number: - Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) � — p (office) <br /> MailingAddress: a�� ,"�fJ City:(,�/c� . S"f��' ' <br /> Contact Person: � .e;������� Applicant is: Contrac or / Qmeowner (Circle One) <br /> Email and/or Fax: �, q.p�..u,����p,� ,r, ��,(p,,�,��,y� <br /> PROPERTY OWNER INFORMATION: � <br /> Name: <br /> Phone (day): -- � <br /> Address: � � � City: " q cz � ZIP: S3p' <br /> Email and/or Fax: � ,� � ,� ; �, �� <br /> PROJECT INFORMATION: Overall ro'ect descri tion: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) Siding �Other: (specify) Phone: 952-471-0590 <br /> ,p Fax: 952-471-0682 <br /> indow(s) t�SWt,�— ��j�l► www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confdential Private data is information which generally cannot be given to the public but can be given to the subject of the data. <br /> Confdential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this infor n is nually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the nfo matio , 'e a lication ma not be issued. <br /> ApplicanYs Signature: Date: <br /> Owner's Signature: Date: <br /> Last Updated:03l06/2013 <br />