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� 4 City of Orono <br /> �a�%��� <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: a0�.3� �b°�(o 3 <br /> �OnI� PO Box 66 <br /> ! Crystal Bay, MN 55323-0066 Date received: ��(8- <br /> ,, <br /> (,� � � � �� Street Address: Received by: <br /> � -��� � - 2750 Kelley Parlcway Plan review fee: � <br /> � ��' Orono, MN 55356 <br /> `�'rf�H����/� � ��l � <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 /> JobSiteAddress: �OS� 1'��9h � c�oc� POZ � C�n6r10 , �''1� �53�`f <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 DepaRment and City Council approva!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/APPLICANT INFORMATION: <br /> Name: C�n1�eP� �.ars�v ���P��+J �- <br /> State License# � �, 5 o (o(o� Expiration Date: 3� 3� ( <br /> Lead Certification Number: Ne T N�c � Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) ��� ��e: �-(3'I�/ (office) �j 5�: -�(7� - ti i� Q <br /> Mailing Address: (�aX y 3o C+tY= r`1 o uN� ZIP: S53i� <br /> Contact Person: �"�M S M 1 r �'� Applicant is: Contra o / Homeowner (Cirde One) <br /> Email and/orFax: �h sw� c rN 3ioz �� -�.RanrlefNef , nl�T <br /> PROPERTY OWNER INFORMATION: <br /> Name: (�j���. (��u�5� <br /> Phone (day): ��z $I �- zo g S <br /> Address: �(n 5� ��G.r..F ,,.i oon p City: O 2otJ o Z�P: �53�� <br /> Email and/or Fax: <br /> PROJECT 1NFORMATION: 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) �r�-K'��o(�K a Q�e.�C" www minnehahacreek orq <br /> Estimated Construction Valuation of Project(excluding land} $ 7D 5� , o0 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all infoRnation 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 /> confrdential. 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 i rmation,the li tion ma not be issued. <br /> ApplicanYs Signature: .x�. Date: � - �� - / 3 <br /> / <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />