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Cit of Orono � `��-s�7 <br /> Y <br /> Building Permit Application for Maintenance / Replacement / Renovation � <br /> - (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O� Mailing Address:-�y � � Permit number. pZ0/�- dU� �!� �` <br /> O PO Box 66 i..1 b -t� ,�' <br /> Crystal Bay, MN 55323-0066 Date received: �` 7—�J'C <br /> Street Address: Received by: � �� <br /> y � 2750 Kelley Parkway Plan review fee: � �ow � <br /> F �, <br /> lqkFSH���, Orono, MN 55356 ��-�/-7 � <br /> o2D � �� <br /> 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: - - - - � <br /> /� �, <br /> Job Site Address: -�t�•��^ 4� ��� - � (�i/�ti�!`G � <br /> Will this be a Parade of Homes, Remodele 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 service will be � <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ::.��: <br /> CONTRACTOR/AP LICANT NFORMATION: "� <br /> �q <br /> Name: � {� �Z/i�'� �Dr S� _ � C �i <br /> � 1 ir�e r ro�'l s.k� <br /> State License# �� 3� Expiration Date: �-� -�p� R� <br /> Lead Certification Number: ,� i - � Expiration Date: � �f� <br /> - (for work on homes that were construc e prior to 1978 � <br /> Phone: (cell) (p�a -���J �� � � (office) ��� <br /> .� <br /> Mailing Address: / a 3 � � c�ty: z�P: ssy �_; <br /> Contact Person: , Applicant is� ontra or / Homeowner (Circle One) �`� <br /> Email and/or Fax: � . �:� <br />_ � <br /> PROPERTY OWNER NFORMATION: <br /> Name: .�Qh c2h ��vl� t�S�� � <br /> Phone (day): � <br /> Address: ��f � � l �_ City: ��'�-r� ZIP: <br /> �� <br /> Email and/or Fax: � � ���: <br /> ;�� <br /> PROJECT INFORMATION: Overall project description: � <br /> �.; <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 /> E�` 18202 Minnetonka Blvd � <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 � <br /> Phone: 952-471-0590 �� <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) �� <br /> Fax: 952-471-0682 • <br /> ❑Window(s) www.minnehahacreek.orq � <br /> .;� <br /> Estimated Construction Valuation of Project(excluding land) $ ` � � � <br /> ::� <br /> APPLICANT ACKNOWLEDGEMENT: ':� <br /> • Agrees to provide all information required or requested by the Building Department; �f,�� <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; �i <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 records and records of other governmental agencies required by law. If � <br /> ou refuse to su I the information, the a lication ma ot be issued. <br /> ApplicanYs Signature: � � Date: I <br /> Owner's Signature: Date: - <br /> Last Updated:03/06/2013 <br /> -rr.-"a <br /> . _ _ �u�a4 <br />