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� "� Cit of Orono r'w` z"S- I � v�sc� <br /> y ���P <br /> B uil din g P ermi t A p plica tion for Maintenance / Re placement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O� Mailing Address: Permit number: c+�0/y. �U/03 <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: �-3 - �� <br /> Street Address: Received by: <br /> y ` 2750 Kelley Parkway Plan review fee: <br /> F � Orono, MN 55356 <br /> `�'�ESH��� J ��!/. �� <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 must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: ���, , � ' <br /> Job Site Address: ,� � `� / y % ��i <br /> Will this be a Parade of Homes, Remodel rs S owcase Home or other Display Home? ❑ Yes No <br /> If yes, a special event perrnit is required with Police Department and City Council approva160 days pnor to the event. Shuttle bus rvice � .6e <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT II�FORMATION: <br /> Name: ��!E�1�`�"��� �� <br /> State License# � 2, -�"j� ' Expiration Date: —� /�J Jj'�� _ <br /> Lead Certification IV�umber: ���.. -h j— Expiration Date: L��,F,-���<� <br /> (for work on homes that we�structed prior to 1978 <br /> Phone: "� (cell) '� �' •�' ��,��� (office) /`;�-� ._ — '"��� <br /> Mailing Address: � � ' � � Cit :,� —.'�1, <br /> Contact Person: � � � Applicant is: Con actor Home wner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> �' Name: <br /> Phone (day): <br /> Address: City: ZI P: <br /> Email and/or Fax: _ <br /> � '" i <br /> PROJECT INFORMATION: Overall project description: ! !�� f' �) �'' _ �-'-� ��" <br /> Type of Project: Any earth movement may o 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) $�,�,���J`� <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 �ata 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 inf rmation, the ication ma not be issued. <br /> ApplicanYs Signature: Date: ;�"—� `� <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />