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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> i�O� Mailing Address: Permit number: <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> � �. <br /> Street Address: Received by: <br /> tiF �� 2750 Kelley Parkway Plan review fee: <br /> t � Orono, MN 55356 <br /> �k�s��a�� <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 �/g� � c�ci � �T, �G��,c� �S�c� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o <br /> /f yes,a specia/event permit is required with Po/ice Department and City Counci/approva/60 days prior to the evenk Shutt/e bus s rvic wi//be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICCANT INFORMATION: n ( - <br /> Name: �vl��,��-t Ct-�.:���e Co..-�S.�v�.ct-�o.-. Q-�f-t- i�o�.� �c�J is �-L'S�o`���'--. <br /> State License# ��,3���� ° Expiration Date: <br /> Lead Certification Number: �p����c�� ,�tl Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �32v- c�/-/Zv� (office) G-S �- ��� � ��� <br /> Mailing Address: �� ��„��,�, � �J�-, S�e-# ��� City: � . _, ' ZIP: S J%zS <br /> Contact Person: S�; Applicant is: ontractor" / Homeowner (Circle One) <br /> Email and/or Fax: �,,,h� .�� � <br /> -�-C�� r��/-v.s"a _ ���� <br /> PROPERTY OWNER INFORMATION: <br /> Name: ����;.� �ra; � /� <br /> � , ,�. <br /> Phone (daY)� 9.S�z-Z� -`�7%� (�"�z`� <br /> Address: 1�b'C� Q�;�c/ S /�c�;� �O�c-� C� � `� ' � ZIP: �SJ'�,� <br /> Email and/or Fax: (rMsC,��_�,(���Ic�°�,_,�;�, r�,.,,,,� <br /> PROJECT INFORMATION: Overall roject description: �� ���,� �-.�.�: � �.-t_ ��a« �«�-f� , .�;h �,c� <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.ora <br /> Estimated Construction Valuation of Project(excluding land) $ 2�� 7�/$ <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 in�or atio , a lic ti ma not be issued. <br /> ApplicanYs Signature° -�� �!�-� Date: �� %�_3 <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />