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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 Mailing Address: Permit number: J �j"� 7 �— <br /> PO Box 66 <br /> � � Crystal Bay, MN 55323-0066 �ate received: Q<3—/3 <br /> Sfreet Address: Received by: <br /> y � 2750 Kelley Parkway Plan review fee: <br /> F �' Oron.o, MN 55356 <br /> l9xfSH�4� <br /> Total Fee: l g� . ��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 applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ~; ��7n (�/ C, yc..�� �(J -{� (��' � � <br /> Will this be a Parade of Homes, Remodelers Showcase Home 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 se-rvice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATI N: <br /> Name: �,, p N� �ti > <br /> State License# (3 �J n� �- Expiration Date: 3 ' 3 � - ) � <br /> � ����- <br /> Lead Certification Number: NRT -3 l q Q -1 � Expiration Date: - �j � , l`� <br /> (for work on homes fhat were constructed prior fo 1978 <br /> Phone: (cell) � � 2, � � (office) � G 3 �Q g 7 �{0 � <br /> Mailing Address: City. nti'� ZIP: <br /> Contact Person: �� ��1 � 2�,� Applicant is: ontrac o / Homeowner (Circle One) <br /> Email and/or Fax: � ��2�) � Y�A lJE1(�, 1 C�,�� �n�c.�� � , JQ�J b N �..��E. C.byl�, <br /> PROPERTY OWNER INFORMATION: ,/� <br /> Name: �(�1��.,y `�' (1�.�1�j�IL <br /> Phone (day): (� <br /> Address: 3g a o D!G�. O � U'� ��' City:SP�j'►1J(, �� ZIP: �� � g� <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 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) 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 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 information,the a lication ma not be issued. <br /> Applicant's Signature: Date: Q -- �3 ' � � <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br /> � <br />