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City of Orono <br /> '�uilding 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: ��v/ '� <br /> Street Address: Received by: <br /> y G� 2750 Kelley Parkway Plan revie ee: <br /> F <br /> t �, Orono, MN 55356 <br /> �k£SHO� <br /> Total Fe �j <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 appfications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: r<;;;s (y� ✓�ja� l� v C� <br /> Will this be a Parade of Homes, Rem delers Show ase ome 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 service 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: o �-v v� T rU•C�b� � <br /> State License# L 6 Expiration Date: Zv ' <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: pa �,•� .,� �� h �, 2� City: '��� ZIP: s� j — <br /> Contact Person: �� ,� Applicant is: ontractor Homeowner (Circle One) <br /> Email and/or Fax: /�X�z� � �Cj���Uj����u.�a<t�fs�l L ,�� '^'� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �C�1� C?�S'� ✓1 <br /> Phone (day): 9S`Z —yUtl—�Z6/ <br /> Address: ��6 f ����� City:��� �����,,� ZIP: s sj� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> �Re-roof,asphalt ❑ Repair �orm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Re toration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) Siding Dlue , ❑ Other: (specify) Phone: 952-471-0590 <br /> f �s��v� , Fax: 952-471-0682 <br /> ❑Window(s� ���c�r-a;,;Nn i�rL��� www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 2 J,�c�U <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'n ormation, e a lication ma not be issued. <br /> ApplicanYs Signature�' ..�1 Date: � � ZG/ 3 <br /> Owner's Signature: Date: <br /> Last Updated: 03/06/2013 <br />