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G�Q�ee' �1-23-f 3 <br /> Cit of Orono � �33 � <br /> Y <br /> , Buil�ling Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> / Mailing Address: permit number: /,?,' -D� � <br /> / ���0 PO Box 66 <br /> � Crystal Bay, MN 55323-0066 Date received: g��/,� <br /> Street Address: Received by: �� <br /> ti � 2750 Kelley Parkway Plan review fee: ��U� � <br /> `� �' Orono, MN 55356 <br /> ��kesfi`��� Total Fee: ��3-�7 <br /> Main: 952-249-4600 Fax: 952-249-4616 wvvv�a v�u��� ;��� ��:, � <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: //_SG Ly-�<:.� ,��- c��-'�a /'"� ��-��� <br /> Will this be a Parade of Homes, Remod ers Showcase Home or other isplay Home? ❑Yes � No <br /> If yes,a specia/event permit is required with Police Department and City Council approva/60 days prior to the event. Shutt/e bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORII�IATION: <br /> Name: �j,,� `` .- ��c� <br /> State License# 1 � S��CS� Expiration Date: � 3, C' <br /> Lead Certification Number: �� Expiration Date: -- <br /> (for work on homes that weie construct d prior to 1978 <br /> Phone: (cell) '7 fG �• Z�'�; - Z�29 (office) 95 2� �Z(�, � �;�j 1 <br /> MailingAddress: 'Z3y,� t �,"�I� S��t-�-� City: �,,g L�„ ZIP: SS3�, <br /> Contact Person: nS �e,S Applicant is: rac r / Homeowner (Circle One) <br /> Email and/or Fax: �, rteS �e�:�oo�'�t�eS.��� <br /> PROPERTY OWNER IN�QR�TION: <br /> Name: lj� -� ��,; <br /> Phone (day): �}'S2-Z?��- (���,�"� <br /> Address: //Sp Ly�,� �_ City: �ru� ZIP: SS��� <br /> Email and/or Fax: f,S - �'�._(o�S'� <br /> PROJECT INFORMATION: Overall ro�ect descri tion: <br /> Type 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) - � �-� Ar S�`fr_..J-�_� _� <br /> Estimated Construction Valuation of Project(excluding land) $ 1 .r-l� <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 upd our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the infor � a ion ma not be issued. <br /> ApplicanYs Signature: Date: c.� !2- ,' <br /> Owner's Signature: � Date: �(I�L' �� <br /> Last Updated:03/O6/2013 <br />