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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�O Mailing Address: Permit number: —�� <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: �Z "3� � � <br /> � � Street Address: Received by: <br /> ti G� 2750 Kelley Parkway Plan review fee: <br /> � <br /> � �. Orono, MN 55356 <br /> �kfShtO'� �l• �� <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: j <br /> Job Site Address: ���� ���5 Gt.✓� c'1� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> /f yes,a special event permit is required with Polrce Department and City Counci/approva/60 days prior to the event. Shuttle bus service wi/!be <br /> required unless applicant demonstrates suffrcient on-site parking is available. Non-permitted events will not be albwed. <br /> CONTRACTOR/APPLICANT INFORMATION: � <br /> Name: •� J�C�/�C, � , Q, <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed piior to 1978 <br /> Phone: (cell) (9� Z- �j — �j- �....(,� (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: ��-�� G� f,� �f�.�.� • �,�v� <br /> PROPERTY OWNER INFORMATION: � <br /> Name: 1�1c�.�,1•�� ��cJ�4,� <br /> Phone(day): (Q�'L,- "' � <br /> Address: a"��� ' ' �..t City: (�,�-V� ZIP: �3�j� <br /> Email and/or Fax: �,r� � � Q �y �f�� ��,n� <br /> PROJECT INFORMATION: Overall pro ect descri tion: � C, +n ���^`�^ �,� w�:c�� <br /> Type of Project: Any eart ovement 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 j�Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑Siding ❑Other: (specify) Fax: 952-471-0682 <br /> ❑Window{s) www.minnehahacreek.orq <br /> Estimated Construction Vatuation of Project(excluding land) $ �(7� U� <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 to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the i f r ation, the ica ion ma not be issued. <br /> AppticanYs Signature: ?� Date: /� � �U ' / `� <br /> Owner's Signature: ��- ^ Date: l � r .3� � (`r <br /> Last Updated:03/06/2013 <br />