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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 /> �O�O Mailing Address: Permit number: oL-O /y- DD '�'/OS <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: � /`f / <br /> Street Address: Received by: � <br /> y�, �' 2750 Kelley Parkwa � Plan review fee: <br /> l,9kFSH���C' Orono, MN 55356 �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 /> Job Site Address: � S c'� �jE��y v <br /> Will this be a Parade of Homes, Remodelers S case Home or other Display Home? ❑ Yes � No <br /> If yes, a specral 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/APPLI�CA1NT INFORMATION{•� <br /> Name: (��� �o o � _�K u; ���(� ,L.�c <br /> State License# � 3,��r� Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (���., _3��- p ry t�c� (office) q lj �- - ��� - �S/� <br /> Mailing Address � p � � „ , City: _"x�-�.�s;o- ZIP: $S 33/ <br /> Contact Person: EU ` � o Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: �„� ` �o,,,� <br /> PROPERTY OWNER INFORMATION: ��. <br /> t L � <br /> Name: �o �,ee_ ��wcJ St-�Ve L���.1C� I�,+Lq <br /> Phone (day): ���� .- ��g-pQ� �r <br /> Address: �� c�.p KC j�a a�� City: ���_, � ZIP: <br /> Email and/or Fax: <br /> r l <br /> PROJECT INFORMATION: Overall pro�ect description: � �r - � o c -��� �t`� �;,,o, I ��- � �$yZ} <br /> Type of Project: Any earth movement m Iso require � <br /> Door(s) „�Remodel ❑ Fire Damage <br /> 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) $ I �,� � � <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 the inforrr�ation t e a lication ma not be issued. <br /> ApplicanYs Signature: 1 Date: � � ( <br /> Owner's Signature: Date: <br /> Last Updated: 03/06/2013 <br />