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• ' ,� 3�. �� <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> '`�`'\ Mailing Address: Permit number: DI�J—�Da� J <br /> �"� ���, PO Box 66 _ <br /> Crystal Bay,MN 55323-0066 Date received: — �� <br /> Street Address: Received by: <br /> �� 5.�, ` 2750 Kelley Parkway Plan review fee: � -rw �- <br /> � <br /> � Orono,MN 55356 �.�/ <br /> ��1HC� t' 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. (P/ease print) <br /> GENERAL INFORMATION: `,n � `� <br /> Job Site Address: �c.�� NU1r�lJl.► 1� �• <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> lf yes,a specia/event permit is required with Police Department and City Council approval 60 days prior fo the event. Shutt/e bus service will be <br /> required un/ess applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLIC T INFO TION: <br /> Name: � 1 , <br /> State License# Expiration Date: ;��inc� �p� �p�rmG�o�1 <br /> Lead Certification Number: _ - Expiration Date: 3 <br /> (for work on homes that were nstrur�e prior to 1978 <br /> Phone: (cell) � _ �(Q51J 7Z��N3 (office) (pSl��7y—v?6b ! <br /> MailingAddress: 'W� t,� '� City: IP: ��\�-- <br /> Contact Person: `g Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER II�F,Q R TIO n - <br /> Name: 1 ���Q�✓.�U1�\ <br /> Phone (day): <br /> Address: � ^ �(' ^ City: ZIP: �J��Q4 <br /> Email and/or Fax: �� ' � � ���m <br /> PROJECT INFORMATION: Overall ro'ect descri tion: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �emodel ❑ 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) $ <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 nnot be given to the public but can be given to the subject of the data. <br /> Confidential data is information whic ally cann e given to either the public or the subject of the data. Our purpose and <br /> intended use of this infor 'o ' t annu y upd ur records and records of other governmental agencies required by law. If <br /> ou refuse to su I th mf ,the lic o ma not be issued. <br /> Applicant's Signature: Date: l l3 <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br /> , <br />