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� City of Orono ���j �
<br /> � Building Permit Application for Maintenance / Replacement / Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> �O�O Mailing Address: Permit number:
<br /> PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> -� �,
<br /> Street Address: Received by:
<br /> ��, G� 2750 Kelley Parkway Plan review fee:
<br /> lqk�SHO4�, Orono, MN 55356
<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: �� _`�� , -�: � ;�,t�� � � �'°J�'�--�.
<br /> Will this be a Parade of Homes, Remodelers Sh wcase Home or other Display Home? ❑ Yes No
<br /> /f yes, a specia/event permit is required with Police Department and City Council approval 60 days prior to the event. Shutt/e bus service wi//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: �Ltin�� <-�-r;5-� s-t�<�����•-� � �-'��,P �I:i � .
<br /> State License# ,��5 ���� �y r� Expiration Date: 3 -,��- �,�
<br /> Lead Certification Number: j/�;;,.� ,'S � �>'��„ Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) C��� -�� J -�/�`��,�„1- .���-.1z3 i(office) i�� �- ��� -//�c�
<br /> Mailing Address: Si�� i N� ,S� 5��,��1. Sr�t>�'� Cit :�,;�� ,, �,, /; �s ZIP: �S�Z Z-
<br /> Contact Person: �����,�� o� �,;� ���,,,�nh Applicant is: Contractor '/ Homeowner (Circle One)
<br /> Email and/or Fax: r,,f�,,,��,� � ����_��-�� . ��-,�,.�
<br /> �--
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: L+�r� �� /.��� � l��'`�`�
<br /> Phone (day): �i� -�y� - �l,.Z�� �
<br /> Address: ��S< <-���-,, -��• �s�<,Is �� �.rJt�s-L City: �lY`03",U ZIP:
<br /> Email and/or Fax:
<br /> a-e_r�u� s��.��_�.�> ;n y,f� n-�c:s-��.�.�_ �:�:�-�,> -��s�t�1
<br /> PROJECT INFORMATION: Overall project description: !� �=�i ^�_ ��, � �^-; .� , �.�P P�-�'�� s��� ��,
<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) S��-�-«-�' �-���, G`"" ° a s, �t..� �.minnehahacreek.orq
<br /> Estimated Construction Valuation of Project(excluding land) $ Z S �rv
<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 i rma � ,the a lication ma not be issued.
<br /> ApplicanYs Signature: � �` � �----�_- Date: 3 `� , J � ��
<br /> Owner's Signature: Date:
<br /> Last Updated: 03/O6/2013
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