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�- 1`� <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> � (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> ;���A, Mailing Address: Permit number: p�D/ -� �(� 3 <br /> ,y PO Box 66 ( <br /> / � Crystal Bay, MN 55323-0066 Date received: - { " � <br /> Street Address: Received by: <br /> � �%I 2750 Kelley Parkway Plan review fee: <br /> �"� Orono, MN 55356 <br /> `�kfSH��� Total Fee: �G3 3 � �/' <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. (P/ease print) <br /> GENERAL INFORMATION: � .. /� / <br /> Job Site Address: \ r , '�,� (.�o �-`t' ( ' �ilil <br /> Will this be a Parade of Homes, Remodelers Showc e Home or other Display Home? ❑ Yes 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 s rvice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP CA T INFO MATION: <br /> Name: _ ,`, � y-. <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) � •-�f� -6�3 �j (office) '� � -_ C��/ -��' % <br /> Mailing Address: lp City: ZIP: C ' <br /> Contact Person: � Applicant i : ont actor ,Homeowner (Circle One) <br /> Email and/or Fax: , �� <br /> ,�e , � <br /> PROPERTY OWNER I,Nr,�OR T��: <br /> Name: �li���: L� /C� �l� �� <br /> Phone (day): � <br /> Address ��3'73� ���L,�u��ti S� h �r:t�J'� City:���l/l� ZIP: �JS,��� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall pro�ect description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt � epair ❑ 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.orp <br /> Estimated Construction Valuation of Project(excluding 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 alternative but to <br /> reject it until it is complete; <br /> • Some or all of the information that yo are aske provide on this application is classified by State law as either private or <br /> confidential. Private data is inform o which g rally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is informati i �e eral annot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this infor t i to ua update our records and records of other governmental agencies required by law. If <br /> ou refuse to suppl the n t+ <br /> ApplicanYs Signature: �� Date: l� � L <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />