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� � City of Orono <br /> � i�� � � <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> O MailingAddress: Permitnumber: �0�����7 <br /> � �O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 5'�$�-3 <br /> Street Address: Received by: <br /> y� � 2750 Kelley Parkway Plan review fee: ��S. D,j <br /> � Orono, MN 55356 0�0/3— � ��� <br /> `�kESH��� 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: ���� ( 7'L� ��>1���4�1 �-�t�l{�- Y� ' ��Z�,�t C ��� ^� c��j 3`i I <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ,�No <br /> /f yes, a special event permit is required with Police Department and City Counci/approva160 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 /> Name: � =�`�t L.l: {�=C�� C"� �k�.(/�� ��> � N L . <br /> State License# ��L,.�(y�j /�l� Expiration Date: _� -._3���2Z�1�� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 3 <br /> Phone: (cell) ��. �L - :�>2 �, - �_.�','3 1 (office) <br /> Mailing Address: '� ;�L'� G � t�.,t (L�' Lr�r�� City: ' =P�rt( ',�.�IP: tj�j.3,� � <br /> Contact Person: "��� n � ���� (N Applicant is: Contrac;r Homeowner (Circle One) <br /> Email and/or Fax: �'�� (��1��TI� ��G�,t(t�111�'�t 1'l l'E� : C � ►rl <br /> PROPERTY OWNER INFORMATION: <br /> Name: '_�`����� �_�J� �' ��-!� <br /> Phone (day): (��Z— 2,� `� — � L,`I s�_ <br /> aaa�ess: •3�-I 7e t3� �C� 1;�3-�� c�ty: �' '�'N��� ziP: �53`i I ' <br /> Email and/or Fax: ��f� <br /> PROJECT INFORMATION: Overall project description: �"= �1�.S �TC� '�l�-L1-- <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 /> Fax: 952-471-0682 <br /> ❑Window(s) 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 /> 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�nf rmatio is to annually update our r �ords and records of other govemmental agencies required by law. If <br /> ou refuse t �u I the' for ation, a licati ma nf be issued. <br /> ApplicanYs Sigr�ature� --�--�-�"�'��� ���-- �� Date: `�-' � ��C'� � ������' � � <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />