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� City of Orono <br /> `Building Permit Application for Maintenance / Replacement/ Remodel — Residential ONLY <br /> {i.e. w�ndows, doors, sidirag, re-roaf, e#c. — Nt3 S�'RllCTURAL EXPANSION) <br /> %-.�0�� Mailing Address: Permit number: 2���+���� <br /> O\� PO Box 66 <br /> Crystal Bay, MN 55323-0066 Z J Date received: �— —( <br /> rr �, �i <br /> i � Received by: 7�� <br /> ; r i Street Address: `�� <br /> \�� ! `�� 2750 Kelley Parkway �I i 1� Plan review fee: e �a�Fi� <br /> � '` � � Orono, MN 55356 � <br /> \��'FfSHv��/ l' �� t � � <br /> % Total Fee: <br /> Main: 952-249�600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must e submitted. <br /> Incomplete a plications will be returned. (Please print) <br /> GENERAL INFORMATION:� � � � � <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers Sh case Home or other Display Home? Yes �}-I�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 service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-perrnitted events will not be allow�d. <br /> CONTRACTOR/APPLICANT I `FO ATION: <br /> Name: ���C� �(��.� � L�� <br /> State License# (�,�y,� Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) ��Z ��y9 —�i�(j�j (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Clrcle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORM TION <br /> Name: 'r s <br /> Phone (day): ^ <br /> Address: City: ZIP: �� . 1 <br /> Email and/or Fax: J Z, <br /> PROJECT INFORMATION: Overall project description: <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 /> 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) $ 4 <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 t s nformation is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I he infor ation,th a lication a not be issued. <br /> � // <br /> ApplicanYs Signatur . �1' ' �L. Date: � 6 ! t� <br /> Owner's Signature: � � � Date: � 6 b <br /> Last Updated:January 201Fj/ / / //, <br /> �;��� J !� �l� <br /> G>�� � <br />