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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 /> , '� Mailing Address: permit number:
<br /> i ��oNo� Po�X ss
<br /> � Crystal Bay,MN 55323-0066 Date received:
<br /> ,{ ^ Street Address: Received by.
<br /> ;. `�;% 2750 Kelley Parkway Plan review fee:
<br /> `� Orono,MN 55356
<br /> ��kF�t+���i�� 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: r"- / .
<br /> Job Site Address: �O ��' � ( ;� ,`�� •;'7�'I•i , ' �"•�G�� j��fZ: v) `�J
<br /> Will this be a Parade of Homes,Remodelers Showcase wome or other Display Home? Yes No
<br /> ff yr�s,a special event perrnit is required with Police Depaihnent and City Counci!approva/60 days prior to fhe event ShutUe bus 9eirice wiN be
<br /> reyuired unless applicant demonshates sul�icient onsite parkMg is available. Non-permitted evenis wip not be albw�ed.
<br /> CONTRACTOR/APPUCANT INFORMATION:
<br /> Name: �;,�_�,)V.-, � ., �.�'.,������. <'�,:,��:,�i v� --i C�-�I��� t- ��eVv,,,�J�:�,,�-�1 � l� Ci
<br /> State License# (j L �; y� �;� �, j Ex iration Date: '�/ 3 � /-� U/G
<br /> Lead Certfication Number: ►�j��- -�� �1 � "; -�-( F�cpiration Date: s ; � � ,��},;
<br /> (tw w�o.ic on nomes cnar wane constn.cted prior to l97s �J'
<br /> Phone: (cell) �/ - <�' - (office)
<br /> Mailing AddnesS: +-a i �=.S«v��E i,'���x 1 �)j� City: ��,��r�V! ZIP: �.5 3 �" `j
<br /> Contact Person: -r-=,�,.,�I y!urr�,�y� Applicant is: Contractor / Homeowner �ckd.a,.�
<br /> Email and/or Fax: ��-, L��-.1-.;�� � y"��f�J T����
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �' l i C�',`,..�,"1 �1 �`j�-� W`t
<br /> Phone(daY)� �' - ,' - 1 7�
<br /> Address: z_ � - lu�� �/�'�t..c.C) �v" City: �l� , , �. , ZIP: ��
<br /> Email and/or Fax: `
<br /> PROJECT INFORMATION: Overall ro"ect descri tion: �� �l�t�� � W�"`a.0�.'S
<br /> Type of Project: My ea�th 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(speciry) ❑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) ; G 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 tfie best of hisTher knowledge. The applicant recognizes that they are
<br /> solely responsible for submitting a oomplete application being aware that upon failure to do so,the staff has no attemative but to
<br /> reject it until it is complete;
<br /> • Some w all of the information that you are asked to provide on this application is dassified by State law as either private or
<br /> confidential. Private data is information which generaNy 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 govemmental agencies required by law. If
<br /> ou refuse to su I the information,the a ication ma not be issued.
<br /> ApPlicanYs Signature: +~� ''?7 -�=t% f-�'�°-'— Date: ,��J j� �;5% � ` ;�-i
<br /> r.
<br /> Owner's Signature: Date:
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