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. .. City of Orono ���7
<br /> Building Permit Appiication for Maintenance / Replacement / Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> �O�O Mailing Address: Permit number: V��� `�" —
<br /> PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: l —/
<br /> Street Address: Received by: ���
<br /> ��'r � 2750 Kelley Parkway Plan review fee:
<br /> `�t L Orono, MN 55356 � � ��r„ �
<br /> � F
<br /> �KESH� 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 /> fncomplete appiications will be returned. (Please print)
<br /> GENERAL INFORMATION: �
<br /> Job Site Address: ���-�-��� p�'-E'� /��` �� / t' � <�. '
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o
<br /> If yes,a special event permit is required with Police Department and City Council approva!60 days prior to the event. Shuttle bus servrce will be
<br /> required unless appficant demonstrates suffrcient on-site parking is avaifa6le. Non-permitted events will not de allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> �
<br /> (vame: Stti✓1 S�zJ-�- ���ns r�,��-, ��-. ��;-v�,,t� �ri r .
<br /> State License# � �]��, �� Expiration Date: 3 - �/ - ��
<br /> Lead Certification Number: Expiration Qate:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) (.'c� �� - j'�, (_, -.;Z < 3 �i (office) �� 3 - ��/C-//U��
<br /> Maifing Address: S�c� i � .55 S c+.i�� S�c����� City: �,,, ,:n�.« e%s ZIP: SSy�,z
<br /> Contact Person: Sos�l. ,�L,,,y,w,-,,, Applicant is: Contractor Homeowner (Circfe One)
<br /> Email and/or Fax: ����,,,�`n,� � s �.�h y�.7C.c�� , c�s�-�
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �-/;t'i S � /�e��i> � -���c'Y�
<br /> Phone (day): 1S..Z - �3;� - `� G
<br /> Address: ��,�,t� p��e.,� rj�✓1 Tr-zA-� � City: p�''�3YJ� ZIP: ,5",�35�,
<br /> Email andbr Fax: ���;s�Q ,//�,-�-, � �r,-��r-�� , c.�, ;-,-.
<br /> PROJECT INFORMATION: Overall project description:
<br /> ' 'Type of Project: �iny 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(excfuding land) $ 1v rna� -`'"
<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 taw 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 ' rmat� n,t a ' ation ma not be issued.
<br /> Applicant's Signature: -� � Date: /�` – � �
<br /> Owner's Signature: Date:
<br /> �as:Uodated: 03/06l201;,
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