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� 1 <br /> g� <br /> - City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> O Mailing Address: Permit number: <br /> PO Box 66 <br /> / � 0 Crystal Bay, MN 55323-0066 Date received: — � 5 —� <br /> Street Address: Received by: <br /> % `� 2750 Kelley Parkway Plan review fee: <br /> `� Orono, MN 55356 <br /> r�'�FsttC��'� / )/L g��(�i/ <br /> Total Fee: � i T d v � <br /> Main: 952-249-4G�� Fax: 952-249-4616 www. i. r n .mn. <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 /> ob Sit�e Address.MATION: ��G,� / Z5 �' � �yG,f��Y vt �,Y��� (�Z;'�1C.7 ����(.'� 5 5 7 5 I_ <br /> t <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,a special event permit is required with Police DepeRment and City Counci!approval 60 days prror to the event. Shuttle bus service wifl be <br /> required unless applicant demonstrates suHicienf on-site parking is available. Non-permitted events will not 6e albwed. <br /> CONTRACTOR/AP ICANT INFORMATION: <br /> Name: ��i � ; �, <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homas that were constructed prior to 1978 <br /> Phone: (cell) �7(p�j� j((,� (�?��� (office) <br /> Mailing Address: LSC , City: ZIP: '�' <br /> Contact Person: p� Applicant is: Contractor / omeowne (Clrcle One) <br /> Email and/or Fax: � l �.z, ; <br /> PROPERTY OWNE INFORMATION: <br /> Name: � �,.� � <br /> Phone(day): `}(p3 -5�1 - ' <br /> Address: 2�, � (�! ,Cer;� (.t'r�dz City: ��7°l�C� ZIP Cj �� �� � <br /> Email and/or Fax: �����_,;a�� g�1�� , �,��,y� <br /> PROJECT INFORMATION: Overall ro�ect descri tion: <br /> Type of Project: Any earth movement may also require <br /> �Door(s) �Remodel ❑ Fire Damage <br /> MCWD review 8�permits: <br /> � Re-roof,aaphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> �Re-roof,other pecify) Siding ❑Other: (specifyj Fax: 952-471-0682 <br /> i <br /> �� Window(s) www.minnehahacreek.ora <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 aRernative 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 re�rds and records�f other governmental agencies required by law. If <br /> ou refuse to su I the informati ,the a lication ma not be issued. <br /> Applicant's Signature: _;:� Date: <br /> Owner's Signature: l "� Date: ��l /�� ��1 <br /> Last Updatetl:03/06/2013 <br />