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( <br /> � City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O . ` Mailing Address: Permit number: ��,`j�'��j <br /> 1`/0 CrysBtal Bay, MN 55323-0066 Date received: .3�3��5 <br /> � 1 <br /> Street Address: Received by: <br /> ti�, � 2750 Kelley Parkway Plan review fee: <br /> t � Orono, MN 55356 <br /> qKfSH��� <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. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: � � .��'� �► '_�. �...' �'�.rJ , � �j `� � <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 servi e will be <br /> required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: S��`/'�- �1 ��Lo L��, <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) —. ' �^., (office) <br /> Mailing Address: " ��:� = �v p� j� City: � ?.p � ZIP: �� � <br /> Contact Person: Applicant is: Contractor /` Homeowner �c�►�ie o�e� <br /> Email and/or Fax: <br /> PROPERTY OWN�INFORMATION: <br /> Name: ���._.�i � 1 r�' � l, <br /> Phone(day): _� � � _ c� � �_, � � �� <br /> Address: ���''�a����� ���� �'�� Citv:9���,J ZIP:���� <br /> Email and/or Fax: <br /> �-Evv�� fl� {�.�,L.�J �-ft�"� �'� f����l'��"'1^'1 <br /> PROJECT INFORMATION: Overall project description: L Z-'v'i <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage <br /> 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) $ � ' <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 informati n is to an ally update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the infor ation,- e lication ma not be issued. <br /> Applicant's Signature: Date: �l � � <br /> Owner's Signature: Date: � '�a � � <br /> Last Updated:January 2015 <br />