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�ul, 7. 2017 i2; 05?M No. 37�5 P. 1 <br /> , , . <br /> City of Orono <br /> Building Permit Application for Maintenance/Replacement/ RemQdel �t�p�`�,��r�#���`;Q�y�;� <br /> (f.�. w[ndows, doors, siding, re-roof, etc.— NO STRUCTURAL EXPANSION) <br /> �Ay� Mailing Address: psrrii�t aum4�� <br /> ;VO PO Box 66 - �� ei�r�� <br /> Crystal Bay,MN 55323-0066 Aa��[�.c�lv��l;, . � �'f� <br /> Strsef Addr�ss: Rece.'lved by , <br /> ��, � 2750 Kelley Parkway Plan tevteW fee <br /> G Orono, MN 55356 ' ; � � <br /> ��hESHa�"� <br /> Tpk�l'F�� � G�'� ��j <br /> Main: 952-249�fi00 Fax: 852-Z49-A616 www.ci.orono_mn.us ,� <br /> This application form must be completed in full and all required information must be submltted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: �� Q � <br /> Job Slk9 Addre9s; <br /> Will this be a Parade of Homes, R$mqdelers Showease Home vr other Display Home? Yes Na <br /> !t yes, a specla!�vent parmllls iequlred wlth Pollce Dgp�ffm9nt and Gity GoUncl!approve!60 days prror to the evenL 5huftle bus seNrc i11 be <br /> requlrsd unless appllcanf demonstrate9 su(Nc(ent on�ife parkrng ia available. Non permitted evenfs w!!!nof be allowed. <br /> CONTRACTOR 1 APPLIC T I FOR ATION• <br /> Name: � <br /> State License# G'� �xplr'2flon p�te: �v � <br /> Lead Certification Number: Explration Date: <br /> (for work on hom(fhat were constructed prlor to 1978 ( ) �� � � � � <br /> Phone� cell ofFice <br /> Mailing Addres3: City: ZIP: �/� <br /> Contact person: p licant is: n ract Homeownar {ci�c�e one� � <br /> Email andlar Fax� <br /> PROPERTY OWNER INFORMA ION: � � /�.�-. <br /> Name� � A �/,T�.� C' 4�.V�C�/ ��7,�,,f�--r] U� <br /> Phone(daY): �� [� /�� f�/ � 3�,P <br /> Address: � ` � y City: ZIP: <br /> Email and/or Fax� <br /> PROJECT INFORMATION: Overall pro ect description� � <br /> Type of Proj�ct: Any earth movement ma also requlre <br /> ❑Door(s} ❑Remadel ❑�ire Damage MCWD review&permlt9: <br /> �Re-roof,asphalE ❑i2apair ❑Storrn oamage Minnehaha Creek Watershed Disirict(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Fiestorafion ❑Water Damage ' Minnatonka,MN 55345 <br /> ❑Re-roof,other(apecify) �Sldln4 ❑Other.(specfiy) Phone: 952-471-0590 <br /> Fax: 852-471-Ofi92 <br /> Window(s) wvvw.minnehehacreek.orq <br /> Estlrnated Constructlon Valuatlon of ProJect(excludlnd land) $ —a <br /> APPLICANT ACKNOWL�dG�M�NT: <br /> • qqrees to provlde ell InFormetlon requl�d or requested by the Bullding Departmeni; <br /> . Certifies lhat the information suppliad is true and correct to the best of hislher knowladga. The applicant recognizes that they are <br /> solely tiesponsfble fot submllting a complete applfcetion being aware fhat upon fallure to do so, the staFf has no alfernative but to <br /> raject il unti�it is complete; <br /> • 5ome or all of the informalion 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 gi�en lo the public but can be glven to the subjeet of the det�. <br /> Confidential dala is informalion which generally cannot be given io either ihe public or the subject of the data. Our purpose and <br /> intended use of this inPormation is io annually update our records and records oF olher g �ermm �tal agencles requlred by I�w. If <br /> ou reFuse ta su I he InF rmet n e a Ilcatlon ma not be Issued. <br /> Applicant's Signature� !1� Date� � � <br /> Owner's Signature� Date� <br /> Lasl Updaled:January 2018 <br />