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� �► , � City of Orono <br /> Bu�ilding Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> ��� Mailing Address: Permit number: -���� ��`��� � ! � <br /> PO Box 66 C � � <br /> 0 Crystal Bay, MN 55323-0066 Q Date received: � �``� <br /> 6Ci Received by: �C =���-- /K� <br /> Street Address: <br /> y�, ` 2750 Kelle y Parkwa y � P l a n r e v i e w f e e: /� i'�I([�°� �, !�l <br /> t,y ��,�' Orono, MN 55356 ����� �(_ ,�,��/ ��C_�_ �� , <br /> kESH� 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 submitte � <br /> Incomplete applications will be returned. (Please print) �� <br /> GENERAL INFORMATION� � / ^„ � <br /> Job Site Address: � � �/l <br /> Will this be a Parade of Homes, emo eler Showcase Home or ther Display Home? ❑ Yes o <br /> lf yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service ll be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/AP LICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were consfrucfed prior to 1978 <br /> Phone: (cell) �2 � (office) <br /> Mailing Address: City: , ZIP: Z <br /> Contact Person: Applicant is: Contra or / Homeowner (Circle One) <br /> Email and/or Fax: �. <br /> �ROPERTY OWNE INFOR ATION: <br /> Name: j f d 2- ? <br /> Phone (day): �� <br /> Address: � City: ZIP: <br /> Email and/or Fax: <br /> • d . <br /> PROJECT INFORMATION: Overall project description: i ���_� C� � - �, l �__ :.� <br /> Type of Project: Any earth move ent may also require <br /> ❑ Door(s) r 2emodel ❑ Fire Damage MCWD review&permits: <br /> � Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage <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 ich generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this infor at' is t annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I th i e a licatio sued. <br /> Applicant's Signature: Date: <br /> Owner's Signature: � Date: Z� <br /> Last Updated:January 15 <br />