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. City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O • O Mailing Address: Permit number. �--�� , `C�C) <br /> 1�T PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: . <br /> y G� 2750 Kelley Parkway Plan review fee: L'����- (� ;z <br /> `� Orono, MN 55356 <br /> lqKESHO�� 3�i - a9 <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. Cn,�- � g <br /> Incomplete applications will be returned. -+Qlease print) � �� 1� <br /> GENERAL INFORMATION: j <br /> Job Site Address: � v �� `� �G�LC� � �= <br /> Will this be a Parade of Homes, Remodelers Showcas ome 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 se ice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non permitted events will not be allowed. <br /> CONTRACTOR/APPLICAN�`{jVFOR�MATION: �l� �� , <br /> Name: (-Jl�w�aE ,� +^ J� ` ✓ <br /> State License# '���j Expiration Date: Z d�� <br /> Lead Certification Number: �'/ 'r_ 'Z v( (� -- � Expiration Date: �� Z � <br /> (for work on homes that were constructed rior to 1978 <br /> Phone: (cell) ( Z �-S?� '7C��� (office) '�7 ���C7 <br /> Mailing Address: j ,1 City: �t :,,i� ZIP: a <br /> Contact Person: � ,� Applicant is: Contractor / omeowner �c�«ie o�e� <br /> Email and/or Fax: '"}�-, P�y, ��r't�u��� +� � c-�-, <br /> PROPERTY OWNER INFQRM�4TION: � <br /> Name: J�c,�, ���,��,,� <br /> Phone (day): (p?2 S �!S <br /> Address: 2 �� 2 � ` ,� City:� y���� 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) �model ❑ 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 /> ❑ 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) $ <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 /> ApplicanYs Signature: Date: � <br /> Owner's Signature: Date: --' ^ <br /> Last Updated:January 2016 ;��� <����� �i 1 p//� <br /> G��%" � �JC 6 ���G! <br />