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c��� �• <br /> �!���" . <br /> . l� <br /> City of Orono 9�3 <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> n��O Mailing Address: Permit number: � 0 :�" <br /> �- 1 PO Box 66 ,_ <br /> Crystal Bay, MN 55323-0066 Date received: �- —/ <br /> Street Address: Received by: � <br /> % � 2750 Kelley Parkway Plan review fee: <br /> � �L Orono, MN 55356 <br /> ��`F��a� Total Fee: /'"7 /� �i /^ <br /> Main: 952-249�4600 Fax: 952-249-4616 www.ci.orono.mn.us G [ � S!/ <br /> This application form must be completed in full and all required information must be s bmitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: i� ��Z. �(�(���T:,E��> �C�\h:�"`� ��C;�� <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 approva160 days pnor to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �..ti� '" ,t�:�7( ���C:(1Lt� <br /> State License# - �3 - � Expiration Date: <br /> Lead Certification Number: �Q-�-��'f � — \ Expiration Date: <br /> (for work on homes that were construcied prior to 1978 � � <br /> Phone: ��lt:c (�' �%S � '2Z2 —�p\ 'r'�c� ��) �vs � — �� S — �� 2—� <br /> Mailing Address: � G �, \� "� �p�Z� City: ��L ZIP: c�;�j ,�3 <br /> Contact Person: ,����; ��L� _ Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: ��.����J��� � n „ �� _ <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��4�--R,� M�RC�ti <br /> Phone (day): (�\Z.— '7�} 3 � 2,�] `) `Z <br /> Address: �c�3� ��j,���� ��,��;"� � City:�j���� ZIP: �js 3Q ( <br /> Email and/or Fax: <br /> �t�S-rqLs� t�� �%�-�— 1z-t�1�-iN�: �Na% vE��—�,t:►C� <br /> PROJECT INFORMATION: Overall roect descri tion: � �\;�c. c'1;�.i�Ec�- �L N ' �`�..�lvC� <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) $ � 't`�, <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 informa n is t ually ate o records and records of other governmental agencies required by law. �f <br /> ou refuse to su I the in ati e a li on not be issued. <br /> C � <br /> ApplicanYs Signature: ' `�`�� -'LZ-- Date: � <br /> r <br /> Owner's Signature: � � Date: <br /> Last Updated:03/06/2013 � <br />