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� . � rZ -i3 <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 O Mailing Address: Permit number: o ��3—a I�S�� <br /> PO Box 66 <br /> , Crystal Bay, MN 55323-0066 Date received: �o /3 <br /> Street Address: Received by: <br /> % � 2750 Kelley Parkway Plan review fee: <br /> tq �,L Orono, MN 55356 <br /> KESHn� <br /> Total Fee: � 7/ /..,�/ <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 /> JobSiteAddress: f��21 �Q� �(-{ �� p� (��-Q/�� , f�/l IJ �Cj.�j(o� <br /> Will this be a Parade of Ho em s Remodelers Showcase Home or other Display Home? Yes No <br /> /f yes,a specia/event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service wi/l be <br /> rgquired unle a licant demo tra e ufficient on-site p r �n is va�lable. No -permilted events will not be allowed. <br /> �iK�7N���� w�w �� ��u��� �r� �,�-r�� c���� <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �� (j� Qc (�. j/t�c/�� �Z I 1 <br /> State �icense# ��. ( Expiration Date: � " (� <br /> Lead Certification Number: _ - Expiration Date: � <br /> (for work on homes that were constructed rior to 1978 <br /> Phone: (cell) �- � (o�ce) �✓ �' - ��� <br /> Mailing Address: `� , N� f-�-(' ( City: �v� P: Gj�` <br /> Contact Person: (�J � Applicant is: n ractor Homeowner �c�r�ie o�e� <br /> Email and/or Fax: ���, <br /> PROPERTY OWNER I FORMA�T)ION: nI \/ c <br /> Name: /V I V�I (,'7 J�(.,,� <br /> Phone (day): 2- U �- �3 7� <br /> Address: I�Z D�TI'� ��N I� c�cy: F�N (� ziP: . �(�,�f <br /> Email and/or Fax: <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) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ `�' `7 - � <br /> �x rZ��lL f I-r�w �, nr��r �M�c v•7 ir"rJ <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 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 not be issued. <br /> ApplicanYs Signature: Q��-�- � Date: � � � <br /> Owner's Signature: Y� � Date: � �Y �3 <br /> Last Updated:03/06/2013 <br />