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City of Orono �°�`� <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: o�O/ �`-'bD 1S6 <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0 66 Date received: /-aa-� �! <br /> Street Address: �� �j <br /> ,�" Received by: � <br /> y�, ` 2750 Kelley Parkway / �{,"�` Plan review fee: 9 S �� <br /> t q R�,�' Orono, MN 55356 �����'�� �D!�-a o o b <br /> KFSHo Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.�n 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: <br /> Job Site Address: �5 g �y��a y1�-(- � � C��� <br /> Will this be a Parade of Homes, Rem lers Showcase Home or other Display Home? ❑ Yes � No <br /> /f yes, a special event permit is required with Po/ice Department and Ciry Counci/approva/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: �pv 1.., 'v` 6 <br /> State License# �, Expiration Date: S-- j- <br /> Lead Certification Number: �(�-T'_ �Q �c..� �� - � Expiration Date: �-�(� .-( <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) ��(�`� -L�j y (office) S ti� <br /> Mailing Address: � ;,� ( �� City:j�, L�� _ ZIP: - �( � <br /> Contact Person: ,� - L.,��� ��,� Applicant is: ontractor •/ Homeowne� (circ�e one) <br /> Email and/or Fax: <br /> PROPERTY OWNE, INFORMATION•J r � � <br /> Name: �j <br /> Phone (day): �� '� p—��_S <br /> Address: � � C N.� � City: Q .•�� ZIP:S'-� 3 ,� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall pro�ect 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 ❑ 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) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ � <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 afternative 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 t information, t lication ma not be issued. <br /> ApplicanYs Signature. � � Date: �^�Z— ��"( <br /> Owner's Signature: Date: <br /> Last Updated: 03/06/2013 <br />