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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> O Mailing Address: Permit number: <br /> �- NO PO Box 66 <br /> Crystal Bay, MN 55323- 0664 Date received: <br /> eet Address: Received by: p <br /> S 2750 Kelley Parkway Plan review fee: <br /> Ft'fkrsrioI�1�� � Orono, MN 55356 338.3.3 <br /> Main: 952-249-4600 ax: 952-249-4616 www.ci.orono.mn.us Total Fee: <br /> This application form must be completed in full and all required information must b submitted. <br /> Incomplete applications will be returned. (PI se print) <br /> GENERAL INFORMATION: <br /> Job Site Address: J J�G 2 5 D i a beo-t* <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 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 INFORMATION: <br /> Name: 5aWko1-5C U . <br /> State License# rt3f(A Expiration Date: <br /> Lead Certification Number: Ntrr_ a4961- I Expiration Date: 15'/3 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) ,3- - 0 Ira <br /> Mailing Address: 1f7t4p L4gvOph4tCity: nSAZIP: <br /> Contact Person: late- �;�1� ,-Je y Applicant is: ontr ctor / Homeowner (Circle One) <br /> Email and/or Fax: r I Zk r-i-1gy @ 5awh;ae, vsDt-colt) <br /> us/} <br /> PROPERTY OWNER INFORMATION: <br /> Name: iC li Cod'J t <br /> Phone (day): q 5d - ;-t 71— 75-Fl ll��. <br /> Address: a�3� 0)) 5eo,,h rV- City: wox ZO fq ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <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) De'N clued !jac P 2 www.minnehahacreek.org <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 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 t annually update our records and records of other governmental agencies required by law. If <br /> you refuse to supply the inf,6rmatioU,the application may not be issued. <br /> Applicant's Signature: Date: WA r/1 <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />