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, • <br /> ` ` 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: �OJ�—��O <br /> PO Box 66 �s� <br /> Crystal Bay, MN 55323-0066 Date received: /l —/ <br /> Street Address: Received by: � <br /> � � 2750 Kelley Parkway Plan review fee: <br /> F �, <br /> `qkES H��� Orono, MN 55356 �{/�<��` � � <br /> Total Fee: f� <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 retur ed. (PI ase print) <br /> GENERAL INFORMATION: 4 � �� �� /�� f' � �� � �� � <br /> Job Site Address: � t:a /� q,�• <br /> Will this be a Parade of Homes, Remo elers Show ase Home or other Displ y Home? Yes o <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus s ice will be <br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowe . <br /> CONTRACTOR/APPLI ANT INFORMATIO : <br /> Name: C.�` Q�� �`�� �[� � <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) _ � -- �'2�. Z � (office) ��Z — �� �j -- �' � " <br /> Mailing Address: � (/ � City: � y/ ZIP: "� <br /> Contact Person: Ap licant is: Contrac r ��" omeowner �c���ie o�e� <br /> Email and/or Fax: � ' Ct,,� � � E <br /> PROPERTY OWNER IN ORMATION: <br /> Name: � �; '�' � � �: L � <br /> Phone(day): � — � ' � � <br /> Address: � �Q, � City: ��� h 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) emodel ❑ Fire Damage <br /> MCWD review 8 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 annual update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I f rmation,t lication ma t be issued. <br /> Applicant's Signature: �� Date: /� ' ���EtVf D <br /> Owner's Signature: � ' -- Date: C ��� � � Z��1 <br /> Last Updated:January 20 <br /> C�T1(OF ORONO <br />