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� City of Orono <br /> Building Permit Appiication for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O�O Mailing Address: Permit number: <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> y � 2750 Kelley Parkway Plan review fee: <br /> `�t �,L Orono, MN 55356 <br /> `4KESH�� 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 prinf) � <br /> GENERAL INFORMATION: , �� � A f� ,c U C�jl� �/�,�(r�,.� L G�/�.� �j,., <br /> Job Site Address: I �� ,lz �—SL� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �';No <br /> !f yes,a specia!event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus s�rvrae wil!be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wil!not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: L�R C�/ �'_� � �- ��i ��«�.� /.� � ��S�Gc�� �e�'=�,5 �_ � �-�, <br /> State License# p� j ��� Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on i►omes that were constructed prior to ?978 l � <br /> Phone: (cell) � —� ' - �' �� �7 (office) �/ �� — � <br /> Maifing Address: � /, �,ti City: ,/►,�,, ZIP: ;� ��j � <br /> Contact Person: �Q � r�i3 Applicant is: Contractor / Homeowner (CircleOne) <br /> Email and/or Fax: � ��+ ��,-j� � [,� �;�� �,5 % . G C� j�✓') <br /> PROPERTY OWNER I ORMATION: l <br /> Name: �/a N ,l-,..� v►-� /►'� �-2_. l�. �l��j <br /> Phone (daY): 7= `� .i " / �� � �J����. <br /> Address: () �, 1� ,,� ��. City:Gl� ' L���ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> '�ype of Project: Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑ 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.or <br /> Estimated Construction Vafuation of Project(excfuding land) $ <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 altemative 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 infor ' n is to annually update: records and records of other governmental agencies required by law. If <br /> ou refuse to su f th mfo ation,th`e licatio n be' sued. <br /> Applicant's Signature: .cn-c � -� Date: � �� �-� <br /> OwnAr's Signature: Date: <br /> Last Upciated 03/06/2013 <br />