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t <br /> f <br /> City of Orono <br /> Building Perm;it Application for Maintenance / �epfacement / �enovation <br /> (No structural e�pansion. Only windows, doors, siding, re-roof# etc.) <br /> "'^_ ' MaiGng Addr�ss: F'ermit number. � ' ` !� � <br /> �-Q�I� , PO Box�66 — <br /> Crystal 8ay,MN 55323-0066 Date received: � <br /> Street Atldress Received by: <br /> �� G�` ', 2750 Kelley Parkway Plan review fee: <br /> t���sW� �, Orono, MN 55356 , � �� ry�� <br /> � I� lJ <br /> Total Fee: l�� <br /> Mairr 952-249-4600 j Fax:1952-248-4616 www.ci.orono.mn.us; <br /> This appliCation form;must be com�leted in full and all required ihformation must be submitted. <br /> Incomplete appllcations will be returned. (Please prinf) ' <br /> GENERAL INFORMATION: <br /> Job Site Address: Q , C O � <br /> WII[this be a Parade of Homes,Remodelers 3howcase;iiome or other Di'splay Home? Yes� No <br /> !f yes,a specia!event perinit is rgquired with Police Depar�ment and City Council approval6Q days pnor to the event. Shuttle bus s rvice wil!be <br /> required unfe5s app6canf demonstrates sufficient on-site parking is availab(e. Non-permiRed events wi!!not be a!lowed. <br /> CONTRACTOR/APPI.ICANTJNF'O ATiON�• <br /> Name: C�/1 �2Y���5 lii�(-W1�j2�V � <br /> State License# a (� � Expiration Date: ,3 " <br /> Lead Certifcation Number. f}- '! Expiration Date: _ �p` � <br /> (for work on homes tfr'at were coristnrcied pNor`to 9978 � <br /> Phone: (ceI!) ' f (office) Lf��'��7— 65� ' <br /> MailingAddress: b / �� e �' y (! ' City: %y�S ZI�': 3 <br /> Contact Person: , �jn , �iy�oV...� Applicant is: : ontracto / Homeow�er �cj.�ieo�e} <br /> Email and/or Fax: ' yti I (�¢. ,Q • COWI', ' <br /> PROPERTY OWNER(NFORMATION: � , <br /> Name: ' t 'f` � C7�.-j'i�QV � <br /> Phone(day): ; � ` ; <br /> Address: C v i City: Y' � ZIP: j <br /> Email and/or Fax: ' � <br /> PROJECT INFORMA710N: Ov;erall ro'ect descri tion:' l�e- 1����� �h ''�ls{�h ' O�Pl�Ivr� . <br /> Type of Project: ; I ' Any earth movement ma also reF{uire <br /> ❑ Door(s) ❑ Remodel ❑Fire Damage MCWD review 8�p�i`mits: ; <br /> ❑ Re-roof,asphalt ❑ Repair �]Storm Damage Minnehaha Creek Watershed'(District(hACWD) <br /> F 18202 MinnetonkaBlvd <br /> ❑Re-roof,cedar I ❑ Restoration ❑Water Damage , Deephaven,MN 55391 <br /> ' Phone: 952-471-0590 <br /> ❑ Re-roof,other(speclfy)I ❑Siding ❑Other:(specify) <br /> � Fax: 952-471-0�82 <br /> �ndow(s) � ' www.minnehahacreek.orq ! <br /> Estimated Constructton Valuatloh of Project excluding land) $ . O (` <br /> � � , <br /> ; <br /> APPLICANT ACKNOWLEDGEIUIENT: � ' <br /> • Agrees to provide all information;required or reqi ested by the Building Department; <br /> • Certifies that the information supplied is'true and correct to the best of hislher knowledge. The applicant recognizes t�at they are <br /> solety responsible fo�submitfing';a complete ap�lication being aware that upon failure to do so, the staff haslno alternative bui to <br /> reject it until it is complete; , � 1 ' <br /> • Some or all of the information that you are asked to provide on this application is classified by State Ia�J as either privafe or <br /> confidential. Private data is informationlwhich�enerally cannot be given to fhe public but can be given to th2;subjecf:of the data. <br /> Confidential data is information�vhich generally�cannot be given to either the public or the subject of the da a. Our purpose and <br /> intended use of thi§'information is to annually u�date our records and records of other governmental agencie�s required by law. If <br /> ou refuse to su I the info�mation thel a lica ion ma not be issued. <br /> Applicant's Signature: ' ' ' ; Date: ' <br /> { /� ,,,/ i <br /> Owner's Signature: f Date: � "1/,���� � . <br /> Last Updated:03l06/2013 ! , � <br /> E <br /> . ; . .. . . � ' i� . <br /> � � <br /> � <br />