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<br /> City of Orono `'��2^13 � 5� S. % ���9�,
<br /> Building Permit Application for Maintenance / Replacement / Renovation
<br /> ' (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> ' OA',�, Mailing Address: Permit number. �� — �/ z
<br /> ' � ,V �� PO Box 66 �—
<br /> � � Crystal Bay, MN 55323-0066 Date received: //-22y I 3
<br /> �� � � Sfreet Address: Received by: ��
<br /> 'F �;� 2750 Kelley Parkway Plan review fee: 3 Z�,3J`� CC.
<br /> t � ` Orono, MN 55356
<br /> '�Krs►��,�1` '� dO/ —
<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 alt required information must be submitted.
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION: /�
<br /> Job Site Address: �� Q S �f'-'�'"L� ���'� G-�N� ��
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No
<br /> If yes,a special event permit is required with Police Department and Cify Council approval 60 days prior to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is avaifable. Non-permitted events wil!not be allowed.
<br /> CONTRACTOR!APPLICANT INFORMA`TION:
<br /> Name: �liia�s-s�y 5 �.c-+�/�",f�''�e'
<br /> State License# Expiration Date:
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes fhat were constructed rior to 1978
<br /> Phone: (cell) G/�- �tj � „?' fj �°_ (o�ce) �� � �'�+ 'Y'
<br /> Mailing Address: �' �3,� S ,�,•�. •�, ,�"'Li,srr � �✓�'4�r City: <•-.�-,�,.,,. ZIP: � �'
<br /> Contact Person: �a s+-+ �. �- ,,,,,P- 2+— Applicant is: Contractor / omeowner (Circle One)
<br /> Email and/or Fax: �;���„�,f �a ,� � ��� , `i,�f
<br /> PROPERTY OWNER INFORMATION: .,
<br /> ►vame: �hOs-n 2��'� ..�c�/��'�2�--
<br /> Phone (day): �j,�-- �,��. - � ��p
<br /> Address: :� ' � � :� + ����°'�"`�
<br /> �C�s � o.�f'h ,�'�"rC ,l✓�'.'s.A: City: G lr,r.��.� ZIP:
<br /> Email and/or Fax: ;,� ,�.,e�% �•�. �'v�,,�,ayyt �;i.a,��L� , y.,e►
<br /> PROJECT INFORMATION: Overall ro'ect descri tion: ���'P'~''� �'`����p�'- ���'``'���'�"�
<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) $___ _ _�,3, O�'d
<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 hislher 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 ' o annua pdat rec rds and records of other governmental agencies required by law. If
<br /> ou refuse to su I the inf n icati a be issued.
<br /> ApplicanYs Signature� � Date: __ �l'�Z'��.3
<br /> Owner's Sign re: Date:
<br /> Last Updated:03l06/2013
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