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• �� /� <br /> • �� �(J1� `�� <br /> / <br /> City of Orono .���`'I 3.r �-�� <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> .- �O A;� Mailing Address: Permit number. a-�/ —0�/ � <br /> 'VO � PO Box 66 <br /> C rystal Ba y, MN 55323-0066 Date received: �—l Z —J <br /> I � � ,� Street Address: Received by: ��c <br /> `,� �.:' 2750 Kelley Parkway Plan review fee: �O�lo, � <br /> �t��_�5F"l��j Orono,MN 55356 d(�1�� 0�/�,� <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. (P/ease print) <br /> GENERAL INFORMATION: '/Q c A_Q��,L V/�I�t/ D�L. . <br /> Job Site Address r�(v O 7 � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus servi e will be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permiKed events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: /� <br /> Name: SC/`f2/�OB'ft- La/N�AN��S <br /> State License# C 5� Z y 7 3 Expiration Date: � <br /> Lead Certification Number: ^/� Expiration Date: <br /> (for work on homes that were constructed prior to 1978 q <br /> Phone: (cell) �/Z- a�0 •�ar3 (office) /$Z• y6s' 35�Z <br /> Mailing Address: �}�,� �jcC I LVD � 3do City: _ LpuK k ZIP: sS5//( <br /> Contact Person: ANQ�'l SCMf2.14bL�7i-/�✓/Z.OD`/ Applicant is: ontractor / Homeowner (CircleOne) <br /> Email and/or Fax: $�Q� SCH2l4be„J�CO�L!/�f�N��'S �p/1� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �A t� '�`L(/2- Q�S <br /> _ _ _ - ____— <br /> Phone (day): gsZ- '](07• L3 D(o <br /> Address: �$S C'o PO�n. v�e�,v D� � c�ty: D/t.o�vo ziP: 5 S 3 S G <br /> Email and/or Fax: "�"'u�KBAS � ShfOGK'DD�To2 • COYN <br /> PROJECT INFORMATION: Overall ro�ect descri tion: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) Remodel ❑ Fire Damage <br /> 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.mir,nehahacre�k.org <br /> Estimated Construction Valuation of Project(excluding land) $ /D�.O�D . -- <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 � orm on,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: ( I <br />