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� � � r ..� <br /> City of Orono � <br /> ry Ruiiding Permit Application for Maintenance / Replacement / Renovation <br />�� � (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br />,�: <br /> � Ar Mailing Address: Permit number: � <br />�� �0�yO PO Box 66 ��3 <br /> - Crystal Bay, MN 55323-0066 Date received: � <br /> 3`' .�n <br /> �'t' <br /> Street Address: Received by: � <br />° y � 2750 Kelley Parkway � Plan review fee: t? <br /> `�t �' Orono, MN 55356 � <br /> �k�SH��� 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. (Please print) :.;� <br /> GENERAL INFORMATION: '� <br /> Job Site Address: ���� �C���� � ✓� � <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 /> ;.�:; <br /> CONTRACTOR/APPLICANT INFORMATION: � <br /> Name: ��n c l�`�_ �Y�T�J`. d('_S — �n�� a <br /> State License# �� �� j� �,j� Expiration Date: �_ �'� <br /> Lead Certification Number: Expiration Date: <br /> �; <br /> (for work on homes that were constructed prior to 1978 �;; <br /> Phone: (cell) C�.� — ���— % }'"7 7 (office) �5�'��y��—�'dG�� � <br /> Rp <br /> Mailing Address: a�;j7_S ��� y� City: � ���w� ZIP: �- _�3�3� � <br /> �� Contact Person: �5 cj( S � �� Applicant is: on� ctor / Homeowner �c��ae ooe� �; <br /> ` Email and/or Fax: � � �r L� �C —� 7 , � <br /> �= <br /> ✓r',, <br /> PROPERTY OWNER INFORMATION: ��' <br />"� �� <br />, / � <br /> Name: � � 7�`� � �l�6t// �� <br /> ;� <br /> Phone (day): �Ja�-3 a �j — �j d 3 � �� <br /> Address: City: ZI P: � <br /> Email and/or Fax: � <br /> PROJECT INFORMATION: Overall pro�ect description: � <br />��:, Type of Project: Any earth movement may also require � <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: s <br />�+ �: ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) ��," <br /> W 18202 Minnetonka Blvd � <br /> .� Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ,� <br /> yt 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) $ /� ��G �� <br /> � �� <br /> ;�a <br /> .7;; <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 /> ��, <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 hich generally cannot be given to either the public or the subject of the data. Our purpose and <br /> ' intended use of this informati is to ann Ily update our records and records of other govemmental agencies required by law. If � <br /> ou refuse to su I t info ation, the lication ma issued. ;� <br /> Applicant's Signature: Date: /'G - Zj—i _3 <br /> Owner's Signature: Date: �,: <br /> Last Updated: 03/06/2013 <br />