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�c.Q�-�- ��2� "�� <br /> . Cit of Orono � <br /> v <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �-''� Mailing Address: Permit number: c72b� `t-� <br /> /%'���/�A Po BoX ss <br /> / \ Crystal Bay, MN 55323-0066 Date received: "'v�a—� <br /> l � <br /> y,, <br /> Street Address: Received by: <br /> ti�' �! 2750 Kelley Parkway Plan review . <br /> � �`-';' Orono, MN 55356 <br /> ���fSN��� � � � / <br /> �__�- Total F e: ��5, 'y- <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 mus <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: '� �G��' S Y�- (�, -�i �b�� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No <br /> N yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus se�vice will be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ��L�t ts��-t-��D�Jt�L/n.(� ��-�lsC'� <br /> State License# j3��Z �s�� Expiration Date: 3 3� /� u� �c�.,t,� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �(0--3..(�-3�j- �/y � (office) 4'SZ- 7�f� -3 7 g 3 <br /> Mailing Address: ����Z �.�����,q..c.f r7 City;/Lf«ati����ZIP: �s3�� <br /> Contact Person: f�i���/� �,c�y�-�� Applicant is: on rac / Homeowner (Circle One) <br /> Email and/or Fax: ����rn�,v-��q L�X�2e-�. C��,,� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �,Cl� /�'�'[.f.� ��`�/ 4.�j25p� <br /> Phone (day): (2�2, '' $O! -' �p��O <br /> Address: r7� ���g�q���� (�� c�ty: ce-,r���tX�- ziP: j�3� <br /> Email and/or Fax: <br /> �0�9T�' ���a Q2 ��vt 5 r� ✓�n�✓3�Bz?�S <br /> PROJECT INFORMATION: Overall pro�ect descri tion: (�0 �b� !�t TCE�c� 7�0 �y��+.c��, <br /> Type of Project: Any earth movement may a so require <br /> ❑ Door(s) ,�Remodel ❑ Fire Damage MCWD review 8�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) R��� ���/ www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ "���m <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 altemative 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 govemmental agencies required by law. If <br /> ou refuse to su I the informatio the a lication ma not be issued. <br /> ApplicanYs Signature: Date: � / <br /> Owner's Signature: Date: =1�2 � ' � -I <br /> Last Updated:03/06/2013 <br />