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' /� � 5� <br /> Cit of Orono C�� ��U <br /> Y <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> i�-,�Q A';:� Mailing Address: � „ �b Z5 <br /> Permit number: <br /> �YO� POBox66 — <br /> �, Crystal Bay, MN 55323-0066 Date received: �/ <br /> 4 <br /> i <br /> (; � Street Address: Received by: <br /> s, �� � ; • <br /> t;. � : 2750 Kelley Parkway Plan review fee: �� <br /> �f� �� Orono, MN 55356 <br /> ?k�St{O,'� /�p/I ,S� <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: � �n " � <br /> Job Site Address: �� �-Y��-� �� 1`�'��S S ��c(L�� �'V1/v 5� 3J� <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 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: �� � L��,�� L . ��.�; "�S 'tS.:f, ���'��,-�. vWv+�l� 1 <br /> State License# xpiration Date: ' <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner �c���ie o�e� <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: (� <br /> Name: 1/V1 �LI.�c,e.� L . Cji.<s'�G�-s��J <br /> Phone (day): -�( 2 - jp� - �j(o`'7 Z <br /> Address: �y.e�,j� , ��' �t S S City: �Vy,,,� ZIP: 5���j"� <br /> Email and/or Fax: _ .�+.�s G S,;��, e -�tic�,s -� �H �;� c; �r � , Cvr,-i <br /> PROJECT INFORMATION: Overall ro�ect descri tion: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑Storm Damage 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) �,��+>�+ I��S�n-.C��" www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ �/Or Ol)� <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 info[fnat' n is t annu ly update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I th ' rm tio ,t on ma not be issued. <br /> Applicant's Signatur�:' �`` Date: 3 / <br /> _. —_... <br /> Owner's Signature:. � � -- Date: 3���� <br /> Last Updated:03/06/2013 <br />