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. _ C�'`;3v-��S <br /> . ��i� a� <br /> ,�o ��i��, <br /> City o� Orono � ___ <br /> Building Permit Application for Maintenance / Replacement / Renovation ���� <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> j" O� Mailing Address: � <br /> / � ^JO��.\ PO Box 66 Permit number. ...� <br /> Crystal Bay, MN 55323-0066 Date received: ' � �—� <br /> I� Street Address: Received by: � <br /> �- � 2750 Kelley Parkway Plan review fee: � l <br /> `�� � Orono, MN 55356 2 <br /> �KFSHO��' d� � � ' �'�J <br /> Total Fee: <br /> M ai n: 952-249-4600 Fax: 952-249-4616 www c���=�c���:��_m n__,_< <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomptete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: t^ �. V� � 0 /j'l .� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> /f yes,a specia/event perrnit is required with Po/ice Department and City Counci!approva/60 days prior to the event. Shutt/e bus ervice wi//be <br /> required unless applicant demonstrates su�cient on-site parking is availab/e. Non-pemritted events will not be al/owed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �LEKKt�VPo�. tS�1"��2S, �N�.. <br /> State License# (�0 p(7 a 7 Expiration Date: ��f��j� <br /> Lead Certification Number: �T., �,�q ss'-( Expiration Date: �jL f3o��s- <br /> (for work on homes that were constructed prior to 1978 �p <br /> Phone: (cell) � . (office) �S,?- 800" � <br /> Mailing Address: City: N ZIP: S'S" <br /> Contact Person: Z� ,�, Applicant is: on rac / Homeowner (Circle One) <br /> Email and/or Fax: t, p <br /> PROPERTY OWNER INFORMATION: <br /> Name: ^I OC,Wv tZC, AND LYNN�' S/kG.�SEN <br /> Phone(day): qs���� � 3�S� G <br /> Address: 1,���' F1��N(„Fj C�(;'Z.c(� 1�11�i/tr� City: DI�ONC� ZIP: S'S'-S7 � <br /> Emailand/orFax: �yn�@ �dwlw►�• . [��K <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 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,7ur�ne,;nal_acreek org <br /> Estimated Construction Valuation of Project(excluding land) � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required o�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 inf rma�on the a li tion ma not be issued. <br /> ApplicanYs Signature: -�'� �� Date: Z <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />