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�5.�� ��� .? <br /> City of Orono 3 <br /> 'Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> A, Mailing Address: � <br /> � ��(V PO Box 66 Permit number: b/ (Oj) <br /> � Crystal Bay, MN 55323-0066 Date received: <br /> i <br /> � Received b <br /> �, � Sfreet Address: y� <br /> fi `� 2750 Kelley Parkway Plan review fee: �� "�� 9 <br /> �"��esr�o�e <br /> Orono, MN 55356 �� <br /> ��---� 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 /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: '�3'�i� F�x 5 ����- E'; c.�-�:; I�N . S'��S �- <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. Shutt/e bus service 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: ;T_ �..i�i��4r�:,., +-�-�-- <br /> State License# �� ��� -� y �� � Expiration Date: 3 ' -3 j •� �� <br /> Lead Certification Number. �-��- 3��3�Y. •- i�-t - C; ~� i:? . � Expiration Date: •Z ` <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) r�i-Z - '7`� I - �;�� �. (office) 5���� <br /> Mailing Address: ,2'1 oU �„��:i;�,,�, l�v� N . City: �t „N� �.�.�„ ZIP: �,-�=� � • <br /> Contact Person: �'�����,L, ����ti�y_ Applicant is: Contractor / Homeowner �c��aeooe> <br /> Email and/or Fax: • �` ' - <br /> �i,�? !Ci.i ��/v t.[�.c�P�i.V a S�' t'h�.�U v� S �'�'v`� <br /> PROPERTY OWNER INFORMATION: <br /> Name: ����y �� <br /> �t�.Ur� <br /> Phone(day): ����Z� 'I o t - (G�4�h� <br /> Address: 3?.,-;at; �� 5."t-- City: �;,.,�,,.,;; ZIP: � ;,;� �, <br /> Email and/or Fax: ��N� (,� � � �r; �� �a��. ��•,N <br /> PROJECT INFORMATION: Overall ro�ect descri tion: -I��Lr F� �L� 1�:,•��-r �-��►�1 ��v..s`�, <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 /> ❑ Re-roof, cedar 18202 Minnetonka Blvd <br /> ❑ 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) �-•�-• ���►5� www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $��y� c���� ., �''C� <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 informatio is annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the in ma n, he a lication ma not be issued. <br /> ApplicanYs Signature: Date: `3 1�- ; <br /> t <br /> Owner's Signature: � iv''" � Date: =� �� <br /> Last Updated:03/06/2013 <br />