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Cit of Orono ��`� 5� 2�- ��{ <br /> � . � . Y <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> �(No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O� MailingAddress: Permit number: D��—DD S�� <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: Jr- �7—/ <br /> Street Address: Received by: <br /> y G, 2750 Kelley Parkway Plan review fee: <br /> `� Orono, MN 55356 <br /> lqKESHOR� _ �OS . 9 ' <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 m �t�ed. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 'Z2-�� �j�y� ' e� p���e-- <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes Q No <br /> If yes, a special event permit is required with Police Department and City Counci!approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> r-- <br /> Name: ��,5 ro;�w <br /> State License# r��6 3 9 1 I� Expiration Date: 0 3/3�f Z��� <br /> Lead Certification Number: Expiration Date: <br /> (for woik on homes that were constructed prior to 1978 <br /> Phone: (cell) � (z �c�7 7 j� � (office) "763 7(2. 5 6 SSG <br /> MailingAddress: �7��� ���,`���,��v � � �W r-� ,za City: �,w�,ge, X ZIP: �,5��3 <br /> Contact Person: y��,5 � o S�er� Applicant is��rrt�/ Homeowner (Circle One) <br /> Email and/or Fax: �6� �rz S°1 S�O <br /> PROPERTY OWNER INFORMATION: <br /> Name: c���,,�, � (Z � ��r� <br /> Phone (day): ��3 3�0 �� 6�j <br /> Address: � -Z,s 3 (� �,y v �ew {� 1�..� �, City: p�'d�e� ZIP: SS3`l � <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ R�model ❑ Fire Damage MCWD review&permits: <br /> � Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt ��Repair ❑ S orm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar [�Restoration �ater Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) [�Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> [�Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ $ � Z- <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 /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential 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 information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: // �- Date: �—Z7 � Z d/� <br /> Owner's Signature: Date: <br /> Last Updated: 03/06/2013 <br />