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� . ► � 5 �.75 <br /> � <br /> City of Orono �' ��' 1 <br /> Building Permit Application for Maintenance / Rep acement / Renovation <br /> �No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �1 O Mailing Address: Permit number: o1D/y—D�l 7 <br /> r �0 C�rysBtal Bay, MN 55323-0066 • Date received: a'�9`�`"� <br /> Street Address: Received by: �'os <br /> S. � 2750 Kelley Parkwa <br /> `�t � Orono, MN 55356 �`F Plan review fee: � <br /> �kfSH�Q`�' �'��� o70/�j�— ��� CO <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 all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �c�G 5 t'crN�.1� L,l /G�tiZs�}_ � �� <br /> Will this be a Parade of Homes, Remodelers Showca Home or other Display Home? ❑ Yes 0'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 su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: tZsz;,,,s io.,� L�G <br /> State License# -L Expiration Date: 3�1� <br /> Lead Certification Number: N�,+_ �pg�Zc� Expiration Date: y(�s(�G <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �jS L-S`i0-�f Sa (office) <br /> Mailing Address: �5 City:�,/ �� ZIP: SS3� I <br /> Contact Person: J�l,,,� �j`i,,' Applicant is: ontra tor / Homeowner (Circle One) <br /> Email and/or Fax: �oy,��� ���;s�on nn,n, . Gb.n <br /> PROPERTY OWNER INFORMATION: <br /> Name: �..a r�..:, � ��i��.:ix.El. �c��� <br /> Phone(day): <br /> Address: �n6t �r�,Ud���. �,l City: �„l�„a�L�'� ZIP: SS3R� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall ro�ect descri tion: �ntv- � �- wn l�an. od-t- <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) $ Z00�,Ool� <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 infor ation which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this i orm on is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I he infor ation,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: Z �� 1� <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />