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�''^� . I �l <br /> � ' City of Orono �'2 <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O Mailing Address: Permit number: "��3 <br /> ^/O PO Box 66 a�T <br /> Crystal Bay, MN 55323-0066 Date received: — <br /> i� � <br /> � Street Address: Received by: � <br /> � :� 2750 Kelley Parkway Plan review fee: <br /> yF� �� Orono, MN 55356 <br /> �KEs Ho��� � <br /> f 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 retumed. (Please print) <br /> GENERAL INFORMATION: p ' 1 S 5 ��j <br /> Job Site Address: � � o� �e�`�°�5 � ��` � �'`��``5���` � N ( <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP II�CANT INFORMATION: <br /> Name: � w��� ���e�,e 1' <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) � s Z- N 5�J-�S �S (office) SG�� p s Ct�� <br /> Mailing Address: � � g O {-�e�;�}A c L�-. City: Z ZIP: S S 3�t <br /> Contact Person: �G✓�c� '�,�e �er Applicant is: Contracto / omeown �c��ie o�.� <br /> Email and/or Fax: �z� e�� e 2 Q� o •C:o'^- <br /> PROPERTY OWNER INFORMATION: <br /> Name: ` ti��� 1 e �{� <br /> Phone (day): �S 2- �(S�/-$S J <br /> Address: v e�� ,e L�.. City: (�JQ Z� ZIP: 55,�9( <br /> Email and/or Fax: �Z��e��e,2 y l.�oo •Ca�^ <br /> PROJECT INFORMATION: Overall ro�ect descri tion: O ti c,����5 a, �v'rtv� 6� s�a`�S <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) %�[temodel ❑ 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 /> Phone: 952�71-0590 <br /> ❑Re-roof,other(specify) ❑Siding ❑Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) �"Y�G��� www.minnehahacreek orq <br /> Estimated Construction Valuation of Project(excluding land) $ So d <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 hisJher knowledge. The applicant rewgnizes 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 he lication ma not be issued. <br /> ApplicanYs Signature: Date: � �V�� / <br /> Owner's Signature: � _ Date: � ` 30 "�� <br /> Last Updated:03/06/2013 <br />