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<br /> . City of Orono `'�� � ��a�
<br /> Building Permit Application for Maintenance / Replacement / Renovation
<br /> - (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> j` O �� Mailing Address: Permit number. �D/3— �/ z
<br /> � � N ��, Po BoX ss
<br /> � � \ C rystal Ba y, MN 55323-0066 Date received: //—Z��3
<br /> �� Sfreef Address: Received by: !�d
<br /> � �� 2750 Kelley Parkway Plan review fee: 3 z�.3J`� C�
<br /> � � ' Orono, MN 55356
<br /> � � ' d0!
<br /> \��k�sHO� �� Total Fee: r
<br /> �..
<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 /> Job Site Address: 3� `�� ���'`"'��` ��o�''"" ��'� '�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home ar other Display Home? ❑Yes No
<br /> If yes,a special event permif 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/APPLICANT INFORMA�TION:
<br /> Name: ����r+�.... , ✓�����'�i
<br /> State License# Expiration Date:
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructedp rior to 1978
<br /> Phone: (cell) G/� - � �i `�- .,,,� � ?ea (office) � � �+' '�'F
<br /> 9 �`� Pl s�%.�°ra. J�rGi�r s^ ��v, lp,.� City: ��-':r'.t�.+�. ZIP: ��y"� <`'".
<br /> Mailin Address: � 5 ':�+ �;
<br /> Contact Person: �"'�s�-� ��"t� ,,�,,,a �'"+�- Applicant is: Contractor / omeowner �c�.�ie one>
<br /> Email and/or Fax: r�wf�°�.�.,�.,r-��,,*�- �``*� ��,rr�, G''�,� , 1�,��
<br /> PROPERTY OWNER INFORMATION: ,!
<br /> Name: ��ll�� �C f'�.�.ri��'�'��`�--_
<br /> Phone (day): ��',�- ��. � '� �` �� �
<br /> Address: }�,t�5'� ,�'� s��r='�, ~�i�'rt' ,�'.,-.'��' City: �:;�w���` ZIP: .�'C`'"�'
<br /> Email and/or Fax: ,,�.� ,,�-�.,,�� -.�.�- /� .�.� ,��� , /�.,r
<br /> 4 L
<br /> PROJECT INFORMATION: Overall ro'ect descri tion: ��'"�'"�'`� '`�"�`p�`"� � ''�'�`�`f`f��`�
<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) $ ��, Q�'�'
<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 altemative 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 generall ot be given to either the public or the subject of the data. Our purpose and
<br /> intended use of this information i o annua pdat rec rds and records of other governmental agencies required by law. If
<br /> ou refuse to su I the in n icati a be issued.
<br /> Applicant's Signature� ' Date: �l��Z'��.3
<br /> Owner's Sign re: Date:
<br /> Last Updated:03/O6/2013
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