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DEC/02/2015/WED Ol 0� ..:'�'. Elder Jones Building �.... °' , ��_ °�". :���9 P, 09? <br /> . �'� City of Orono <br /> �` � �3u'rldi�tg Permit Apprication for Main#enance / Repl��ement / Remodel <br /> (i.e. �rri�dav��, door�, �6d�r��, r-e-rc��o�, e��c. — IVQ ST'RUC�'l3R�L ��C��h���t��� <br /> ��y � �a�l f PO Bo�r66� Permit numberb� — �� <br /> � Crystal Bay, MN 55323-006F� Date received: I�Z" <br /> � , Street Address: Recelved by: <br /> r <br /> � � I 2750 Kelley Parkway Plan review fee� ' <br /> �t �' I Orono, MN 55356 <br /> '�k s�oF`�. <br /> ' Total Fee: �-j <br /> Main: 952�249-4600 Fax 952-249-�616 www.ci_orono.mn.us ' � r / <br /> This appliC�tion form must be completed in full and all required infor��atian must be submittod. <br /> Incomplete appllcatlans wll� be returned. (Please print} �� <br /> GENERAL INFORMATION: / <br /> Job Site Address' , � �� � �/' �C� � �/ Q ( �, <br /> Will this be � Parade �f Hames, Remodelers howcase Home or other Display Home? ❑ Yes o <br /> /f yes,a special event permit is required with Police Department and Cify Council approval 60 days prlor to the event. ShUttla bus service will be <br /> required unl�ess applicant demonstrates sufticlenf onslte parking!s airallable. Non-permi�t�+d�+v�nts will nof be allowsd, <br /> CQN7RACTOR/APP�ICANT INFURMATI��1: <br /> PVame� <br /> State License# i THI�At- Home Set'��iee, I�Zc, Expiration Date_ <br /> Lead Certification Numl er 2690 Cumberlai�d�kw�, Ste 300 Expiration Date: �'� <br /> (for work pn hpmes�hat w Atlallta� GA,34339-3913 <br /> Phone: (cQll) Lic#CR?68257�'h. 763/542-8826 '��'� � <br /> Mailing Address� Git ' ZIP_ <br /> Contact Person: q'f? �yf. (,q y � Applicant is: Gpntracto / Homeowner (Gircle One) <br /> �mail and/or Fax: ���� � t c�� r j b n c s. Cro M _� <br /> PROP�l7'TY OWNER II�IFOR�M1ATEON: <br /> Narrte: j� Q?! � � �'1 1�'� � !' n'1 4 � <br /> Phone(day): Z►i�',3 ,'�0 3 . j Q 7 y. <br /> Address: 3;Y 4l '� �,� G� Pl Q C i. City: �G�/ T G 'f�� ZIP: S 5+3 $ I ..`_ <br /> Email and/or Fax: <br /> PROJEGT INFORMATIQN: Overall projec�descriptian: <br /> Type af Project: � Any earth movemenf may also requlre <br /> ❑ Door(s) I �] Remodef ❑ Fire Damage <br /> MCWD review$ permits: <br /> ❑ Re-roof, asphalt �, 0 Repair ❑Storm Dam$ge Minnehaha Creek Wat�rshed Qistrict(MCWD) <br /> 18202 Minnetonka BEvd � <br /> ❑ Re-roof,cedar � ❑ Restoration ❑Water Damag� I]eephaven, MN 55391 '' <br /> ❑Re-roof,other(speciiy� ❑ Siding ❑Other. (specify) <br /> Ph one: 952�71-0590 <br /> Fax: 952-071-0682 <br /> E '�Window(s) � www,minnehahacreek.orq <br /> Estlmated Constructipn Valuatlon of Project(excluding land) $ <br /> APP�ICANT ACKNdWL�bG�MENT: <br /> . Agrees tv provide all informafion required or requested by tl�e Building Department; <br /> • Certifies Chat the in rmation supplied is true and correcf to the best of his/her knowledge. The spp(ic�nt recognizes thaf they are <br /> solely responsible f�r submitting a comp(ete 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 iinforrn�tion that you are asked to provide on this app€ication is classif[ed by State law as either private or <br /> confidential. Privai�d�tt� is information which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is'iinformation which generally cannot be glven to efther the public or the subject of the data. Our purpose and <br /> intended use of this'information is to annually update our records and rer,ords of other governmental �gencies required by law. If <br /> i ou refuse to su 1 the in'Form�ti n, th plication ma not be issued. <br /> Applicant's Signature: ' � � Date: �!��� l� S <br /> Owner's Signature; �i Date: <br /> L�st Updated:January 2�15 <br /> T <br />