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� Cit of Orono � �� 7�� �� <br /> Y <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �r Mailing Address: <br /> ���VO PO Box 66 Permit number: ZU �5'"�' j �S' <br /> Crystal Bay, MN 55323-00 6 Date received: � Z ZZ <br /> � Streef Address: cb' Received by: (�a e�L. <br /> tiF G� 2750 Kelley Parkway \' Plan review fee: ��'� "��e�� ,v� <br /> `�'�ESH04� Orono, MN 55356 <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: I�QO ShA�I�V�DO� f�D(/IOI ��'a �MN 553�I <br /> Job Site Address: I <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No <br /> If yes, a specia/event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will be <br /> required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events wil/not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ,�2V2 �}iCln50�1 <br /> State License# OV3$4 a� Expiration Date: 3 ZQ�� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (pla• �135•(p292 (office) SaM�- <br /> Mailing Address: 530 50 c�ty: A�o ziP: 5�53a <br /> Contact Person: ��q}�j�pn Applicant is: rac / Homeowner (Circle One) <br /> Email and/or Fax: ��Q�u���,�p�L <br /> PROPERTY OWNER INFOR TION• <br /> Name: (��.� A�dbQ,Y <br /> Phone (day): q . . � <br /> Address: � NQ� City: {'� � ZIP: �3� ( <br /> Email and/or Fax: MQ Un �t�lY�.11e,t <br /> PROJECT INFORMATION: Overall roject 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 /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof,other(specify) � Siding � Other: (specify) Fax: 952-471-0682 <br /> �Window(s) �Or(�1 www.minnehahacreek.orq <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 to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the information,the a lication ma not be issued. <br /> Applicant's Signature: � �- � Date: /� vt/ / <br /> Owner's Signature: _� Date: �t��1 � <br /> Last Updated:January 2015�/� ,�� �l���'�` <br /> l./l / <br />