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City of Orono <br /> Building Permit Application for Maintenance / Replacement 1 Remodel — Residential ONLY <br /> {i.� ,...:::_. ;;#erat�, r�•-�c�c�f, �tc. <br /> OA, Mailing Address: Permit number. ,�C� --����1 <br /> � f yO PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: C—/�— <br /> Street Address: ecE�ived by: ` <br /> y�. � 2750 Kelley Park ,� Plan review fee: � �' ,, J y <br /> �� Orono, MN 5535� �� �� ��� , ��pa�d <br /> !�'r�SHO� <br /> 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 submitted. <br /> Incomplete applications will be retumed. (Please prrnt) <br /> GENERAL INFORMATION: <br /> Job Site Address: o�,'��(� ��j�/Gb� �c�1�� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Horne? Yes No <br /> If yes,a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus serv wi!!be <br /> �equired unless applicant demonstrates su�cient on-site parking is available. Non permitted events will not be allowed. <br /> CONTRACTOR/AP LICANT INFORMATION: <br /> Name: G�KK�N�aC. ��U�C.�E'�L.S � .�iVC . <br /> State License# � �pp ' Expiration Date: � � <br /> Lead Certification Number: �j/�T"- 3.�tT S s" Expiratio�n Date: S 2,0 <br /> (for work on homes that were constructed rior to 1978 ► Q <br /> Phone: (cell) (office) q r - a <br /> Mailing Address: � /q� ( 7 City: y�,T'�ja�V ZIP: �'3' p <br /> Contact Person: q 2 i �✓ L 1 Applicant is: n rac o� Homeowner (Circle One) <br /> Email and/or Fax: ( r1 b . GbN'� <br /> PROPERTY OWNER INFORMATION: <br /> Name: (Z,.�!�I�c. y- SEA�NI�' C/4-2T� <br /> Phone (day): � -,S'( 2 <br /> Address: a,�T o Sf�d`�� ���¢p c�ty:C�XCEL�i��C ziP: -..S�3=3� <br /> Email andlor Fax: (���k ,��,r}�Cr' L0 1 hbra rp�GON'� <br /> PROJECT INFORMATION: Overall project description: l�'Z7Z� `f- � t;�(. <br /> Type of Project: My earth movement may also require <br /> ❑ Door(s) �emodel ❑ Fire Damage MC'WD review 8 permits: <br /> � Minnehaha C�eek 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�71-0590 <br /> F=ax: 952-471-0682 <br /> ❑Window(s) wwvy.minnehahacreek.orq <br /> Estimated Const�uction Valuation of Project(excluding land) � C� .�'JD <br /> APPLICANT ACKNOWL.EDGEMENT: <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 infonnation that you are asked to provide on this application is classifieci 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 annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the information,the a ication ma not be issued. <br /> ApplicanYs Signature: � � r� Date: ���O <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />