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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 /> j��O A' Mailing Address: Permit number: / ^d � <br /> 'V PO Box 66 2,,� <br /> i" 0 , Crystal Bay,MN 55323-0066 �l` l Date received: ��� -.�C� — / <br /> � � � SrreetAddress: `!y Received by: <br /> yF �� 2750 Kelley Parkway Plan review fe � <br /> � <br /> t ` % Orono, MN 55356 <br /> �'�ESHO�� � c <br /> Total Fee: � J 4�� <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: .���,� (��,;�,�;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 with Police Department and Ciry Council approval 60 days prior ro the event. Shunle 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: � �� l�;� <br /> State License# ��v�� 3�� Expiration Date: � <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) � _ ��v� (office) <br /> Mailing Address: Ci , -'_ � Ciry: ZIP: <br /> Contact Person: - Applicant is: Con ractor / Homeowner �c�rcie one� <br /> Email and/or Fax: ��`� ��U�`��� ���,� <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: Ciry: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall ro�ect descri tion: <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 /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑W Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other(specify) ❑Siding Other: (specify) Phone: 952-471-0590 <br /> -� Fax: 952-471-0682 <br /> ❑Window(s) �f�L<<M[JUi i.u�c.. 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 inf mation is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I th � formation,t a lication ma not be issued. <br /> ApplicanYs Signature: Date: <br /> c <br /> Owner's Signature: c ' Date: <br /> Last Updated:03/06/2013 <br />