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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> jNo structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O�O Mailing Address: Permit number: <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> Z � 2750 Kelley Parkway Plan review fee: <br /> `� L Orono, MN 55356 <br /> lqkfSHv�� Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 w�,vw.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: :.`S�� �,l y�,��d(� 1(�t�vC. , (Y�,n�`(�(�e�v�� � 11n�N S3�lo'--i <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 wrth Police Department and City Council approval 60 days prior to the event Shuttle bus se ice will 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: _� ������ <br /> State License# � Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �,i� �� ��5�� (office) <br /> Mailing Address: �t S 3 �.�� �y.� n}� City: �� ZIP:SS3i� <br /> Contact Person: '�����o jL/�� Applicant is: Contractor / H eo f (Cirde One) <br /> Email and/or Fax: �������2� r �,,,ls�t �,,�,`, <br /> ��c_u. <br /> PROPERTY OWNER INFORMATION: <br /> Name: �mN �,1c,SExc:1. <br /> Phone (day): �p �.� o �S -�c <br /> Address: 115--3 ��,�,�w��� ►�c., c�-�tx�� yy��V City: �rw�.c� ZIP: 5�3ccy <br /> Email and/or Fax: �� ��� z 1 e �-,rnu;�.Evvr� <br /> PROJECT INFORMATION: Overall ro�ect descri tion: �`'�a��'`'"`j S��`�`�' 5���� �- ��-L'�` 11�fc�`�`"` `E �r`uK� <br /> i% i <br /> Type of Project: An arth movement may also require�� ��. <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: J7- <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 /> t+t�: c�otd�� Fax: 952-471-0682 <br /> �IVindow(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of o ect(excluding land) $ 1�'��e� <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: ���,E�Zs�{� Date: �'` Z--S� 1 3 <br /> Owner's Signature: ���� f C���, Date: `�' -Z��i� <br /> Last Updated:03/06/2013 <br /> � <br />