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City of Orono <br /> Builc'.�ng Permit Application for Maintenance / Replacement / Remodel <br /> ��i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O� Mailing Address: Permit number: �� S–OU Z"-7� <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: '3 — �n—��S <br /> � � ) ,�y�-�- <br /> Street Address: Received by: � �—� <br /> :� G� 2750 Kelley Parkway Plan reviewfee: �-� ` �h /'""' <br /> `qKfSH��� Orono, MN 55356 �-.lU S � � <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 vwvw.ci.orono.mn.us p� �C � �t"s-,�t� .U <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 /> � <br /> Job Site Address: ���� J ���,�t-�/C.L);,Y�i,^ � C�'� � � < ! �r.� ��.4J ��� � <br /> � ���,��.' i <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 service will be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> � <br /> Name: U r , ,-U .v�i r2 " � r .� ' .�-l/��� <br /> State License# �� �J�z�� Expiration Date: ? {3� Z,c�;S� <br /> Lead Certification Number. �(��r ��`"�� �_� Expiration Date: �;,� 2��,�r <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) -,/�- ,�.�%� - �7�ik (office) ��z- 6 2 '�"=-2��lrc�/ <br /> Mailing Address: � t� � �/, 1,���;--r- �� � �,� City: ��-� ZIP: ,*'� ��" �� <br /> Contact Person: �'�.,� tj(t,�;��Z�,�, �Applicant is: ontra �r / Homeowner (CircleOne) <br /> Email and/or Fax: �i (,� g L�� 2`��� � <br /> PROPERTY OWNER INFORMATION: <br /> Name: �iv� ���^/!�t?r�i�"./ai�4� <br /> Phone(day): CS�- �7 C� - ��'3�� '�T ���, <br /> Address ��.�� �j�- <U�,iy� City:�,�:�,�;, >�_ ZIP: `; �y' <br /> � Email and/or Fax: - N �� <br /> PROJECT INFORMATION: Overall project description: � <br /> Type of Project: ny eart 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(MCW D) <br /> 18202 Minnetonka Blvd <br /> c�� ❑ 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 information i nually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the i atio �cation ma not�e issued. <br /> ApplicanYs Signature:..- :_ � � � /' ;, Date: �E'` ��%� <br /> f <br /> / <br /> Owner's Signature: � � Date: <br /> Last Updated:January 2015 <br />