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- City of Orono �'�� ,� <br /> /� <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �Oj _O Mailing Address: Permit number: ��/�— ��8� <br /> l�l PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 7-3D'I <br /> Street Address: Received by: <br /> �- ti 2750 Kelley Parkway Plan review fee: <br /> F G <br /> t �, Orono, MN 55356 <br /> �KESH�� � l�O�•/ I <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: 1. <br /> Job Site Address: 2 S�� r e ��/ Ct v� / <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes C�'No <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 6e allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ,IVJ L�bti4.�� M o d r(�.✓ <br /> State License# �yG ��p j Z Expiration Date: f. <br /> Lead Certification Number: /�/� r 2„!�S"��' Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) ' <br /> Mailing Address: G / City: �. cL P: <br /> Contact Person: '��.,. Applicant is: � c / Homeowner (Circle One) <br /> Email and/or Fax: � <br /> PROPERTY OWNER INF RMA ION: /�� . <br /> Name: �t Gr�f � (J�/'�16t- �fQ��'FIr <br /> Phone (day): <br /> Address: �jg �l..c �u ,rt'v� City: ��C�sta•� Z�P: 5�''33/ <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: �''�'a�{- f�t�� `1 '�" �'``� '"'�,� /� <br /> Type of Project: (�,�A' r1i f�,�.t Q � Any earth movement may also require <br /> ❑ Door(s) �model ❑ 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 ❑ 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.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ C1•O <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 information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I t inform tio ,t e a ication ma not be issued. <br /> Applicant's Signature: Date: �� <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />