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���� . } / �� <br /> C i ty of O ro n o�--1�-� -=�I � �._��:� � i`�3 I- <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> Oq, Mailing Address: Permit number: dQl ' � <br /> � f yO PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: s �a-1 <br /> St�et Address: Received by: r�% <br /> y�, �' 2750 Kelley Parkway Plan review fee: � <br /> L Orono,MN 55356 �� <br /> !q'�ES Ff O�� Tota I Fee: l� <br /> Main: 952-249-4600 F2x: 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: �5��j C,N`�-OS�INL �&- CS�JJt P't1a7 <br /> Will this be a Parade of Homes, Remodelers Sh�v+scase Home or other Display Home? ❑Yes � No <br /> If yes,a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will be <br /> �equired unless applicant demonstrates s�cient on-sde parking is available. Non�ermitted events will not be allowed. <br /> CONTRACTOR/APPLJCANT INFORMATION: <br /> Name: ��.��3� J A.,R-c�� W���;k!,x�-t:��t <br /> State License# ��,=�-?��c���\ Expiration Date: 3 -3� ; ' <br /> Lead Certification Number: �JA Expiration Date_ N,4, <br /> (for work on homes ti►at were consY�utted prior to 1978 <br /> Phone: cell `' � '� � office �i ia?,� �j� �?�i� i <br /> ( )�fo'�i� ��.U-�ia w ( ) <br /> Mailing Address: �i`,�`'i 't�lA�� 5�i", C�Y= ^1A'��.e:, �t-q�� ZIP: �5�Gj�� <br /> Contact Person: i�,� ����,����N��� Applicant is on rac r�/ Homeowner (Circle One) <br /> Email and/or Fax: 'e��',a�.^_—,0:2�—��+,'s-+r;�,.C� /� ( ;��`��+ � �E�.iC <br /> . - <br /> PROPERTY OWNIER INFORMATION: <br /> Name: �.��c,�- �J�c.o�� tJi:,t,��xv <br /> Phone(day): <br /> Address: 5�0 {',J��MP(?,�,(,L C.� tUW C�Y� l�v-�C,N1N5�rr.1 ZIP: cjS�J50 <br /> Email and/or Fax: �`���N�W�����AHcx�.��M <br /> PROJECT INFORMATION: Overall pro�ect description: �'��x-!�.0�` 1Sa��'v�.,2.(t i;cv;4��o�--: ,FE�.�^{, <br /> Type of Project Any earth movement may a o require <br /> ❑Door(s) �Remodel ❑Fire Damage MCWD review 8�permits: <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑Re-�oof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 <br /> ❑Re-roof,ott�er(speci(y) ❑Siding ❑Other:(specify) Phone: 952�71-0590 <br /> Fax. 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ it;C� Oot7 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> . Certifies that the infoRnation supplied is tnae and correct to the best of his/her lmowledge. 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 altemative but to <br /> rejed it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is Gassified 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 subjed of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other govemmental agencies required by law. If <br /> ou reiuse to suppl the information, pplication ma not be issued. <br /> ApplicanYs Signature: Date: S f c�3.I �`� <br /> Ovme�s Signature_ Date: ' <br /> �ast uPaatea:osrosrzo�s <br />