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�, City of Orono <br /> , Building Permit Application for Maintenance/ Replacement/ Remodel - Residential ONLY <br /> (�.�, ��a���ir���. ��r�a�r�, �ic�sr��, ����c��, ���. -� �C� ��"��R��ffi`i.����. ��:����If���� <br /> j� O A�,. Mailing Address: � ermit number: p���p�d/D 9'� <br /> / � j Y� PO Box 66 �� � <br /> ;� , Crystal Bay, MN 55323-0066 Date received: 9 --� <br /> 1�� � SireetAddress: _._..--.---__ Received by;-__. _�_____ �� <br /> ti 2750 Kelley Parkway ''�-��C �C- l�24� Plan review fee. �PD gi��n �' <br /> ���t� .- `t�,G Orono, MN 55356 � � � _ �� � <br /> �k L 5�i O `._._______-��.___ -�8��1.•F�Ar-----�-- -- <br /> Main: 952-249-4600 Fax: 952-249-4616 wwvv.ci orono mn us � Y <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: <br /> Job Site Address: �21 �� l�- S��I.��.���C��� �Z�� <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 Depariment and City Council approval 60 days prior to ihe event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted evenis will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: � � �p <br /> State License# � Q'��(�L-', Expiration Date: 'Zj 2( �j� <br /> Lead Certification Number: ���T_ ���?a_ � Expiration Date: 2( • <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (��Z '�(U -- -1 Z��(SZ (office) (SZ�'Z-�j1LZ-- �,t�:x> <br /> Mailing Address: G)3 (�l/� S�- _ City: v�T,q ZIP: ���� <br /> Contact Person: ( ,�� � Applicant is; Contractor Homeowner (CirdeOne) <br /> Email and/or Fax: �------ <br /> ��11�1 �' �1 i�1G.�M 1�.�,�'.OP✓l <br /> PROPERTY OWNER INFORMATIP N�:'� �, � <br /> Name: S���t�j -I StXS��a �1]�i� <br /> Phone (day): <br /> Address: l� ���� �_- <br /> '�(� ��1�-d.. Iti.)�k`� �D City:- ZIP: ..����1 <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: 1.�� ��- 1G�� t� i�� � S <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 /> ❑ Re-roof, cedar 15320 Minnetonka Blvd <br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof, other(specify) ❑Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> — �Nindow(s) �vwav.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ - C�� `� <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 I <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 /> _.,,,,�.,._....,,,-:;�a—_ , <br /> Applicant's Signaturet'" �� Date: �- /� <br /> Owner's Signature: � Date: <br /> Last Updated:January 2016 C/�L`_ _ � (y ��� //' <br /> i(/r 7 �/� <br />