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Cit of Orono ,�733�• �`� <br /> Y <br /> Building Permit Application for Maintenance / Replace � ion <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O A'O Mailing Address: Permit number: p7Q�,�j-�l0�CY <br /> +y PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: /D -�/-.� <br /> Street Address: Received by: � <br /> 5.F ��J 2750 Kelley Parkway Plan review fee: ,3�j'/,�� <br /> t Orono, MN 55356 <br /> �KESHO�� ���j — ��� �7 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us " ( j ,L.� , �,aj <br /> This application form must be completed in full and all required information must be sub itted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 6�iS' �rJ�S ; �oN � oronl c <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other isplay Home? ❑ Yes No <br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior fo the event. Shuttle bus s rvice 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: Si"cv�.�..��Z L� �— <br /> State License# Expiration Date: <br /> Lead Certification Number: N p� Expiration Date: <br /> (for work on homes that were con ructed prior to 1978 <br /> Phone: (cell) ��Z- �-t- ZC�'10 (office) 1 SZ -6°I�1-S Sa o <br /> MailingAddress ��o� w„_ Z�,-�„ ���L City: M�nnt �b`� ZIP: 55N'Z <br /> Contact Person: sJ<a �-�ks�"�.FsaN Applicant is: ntractor Homeowner (CircleOne) <br /> Email and/or Fax: S�t� �, �-r�nc w��Z � cc,ti. <br /> ,a <br /> .' � "` , �' <br /> PROPERTY OWNER INFORMATION: <br /> Name: -'�l,a � I��c�i�-t ���r� <br /> Phone (day): �12- -7�o - "?3�� <br /> Address: SA,,,�,` �.5 S',-f�,�- City: ZIP: <br /> Email and/or Fax: �r ��µ«� G� ,� �,,,��,;� , c o M <br /> PROJECT INFORMATION: Overall pro�ect descri tion: <br /> Type of Project: Any earth movement may also 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-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other(speciry) ❑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) $ 1 . 2 ,� <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 informati that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data ormation which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is infor io hich generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this in r at� n i to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I ati n, the a lication ma not be issued. <br /> ApplicanYs Signature: Date: �"Z S � i3 <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />