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+ � � City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel - Residential ONLY <br /> (�.e. win�ic�ws, �iaars; siding, re-roof, etc. — NG S� ;URAi.. �XPANSIONj <br /> '� ��` � Mailing Address: Q�g�� a� <br /> j���A,O\ Permit number: <br /> 1 y PO Box 66 <br /> _' � Crystal Bay, MN 55323-0066 Date received: ���'� <br /> 1 `� -�n,, <br /> � ' � Street Address: Received by: 'v�.� <br /> � a ,� <br /> y � 2750 Kelley Parkway ��� Plan review fee: , � <br /> `�t �� Orono, MN 55356 s��� �/�r��a/ <br /> �kF5H0��;% <br /> ____ Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 �>v�ew.c� cronc.�r,n,us <br /> This application form must be completed in full and all required information must be submitt .�O p, C� <br /> Incomplete applications will be returned. (Please print) p J <br /> GENERAL INFORMATION: � <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers Showcase Ho e 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 serv�ce will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> COA�TRACTOR/APPLIEANT IAIFO M�4TION: <br /> Name: ,� <br /> State License# � 5 3 � Expiration Date: � �� • � <br /> Lead Certification Number: �JC��...��� -. Expiration Date: '�. � ,�d <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) � (office) ,� 1� • �Q <br /> Mailing Address: V City: ZIP: <br /> Contact Person: Applicant is: Contracto / Homeowner (Circle One) <br /> Email and/or Fax: �jH�SA��c ���- �^bM P��(�� �C�M <br /> PROPERTY OWNER INFOR ATION: <br /> Name: � <br /> Phone (day): <br /> Address: City: ZIP: 3 <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall pro�ect 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 n-�;r�reer,r;nc�_:;::ek.,JiCI <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 is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I th information, the a lication ma not be issued. <br /> Applicant's Signature: Date: '� ' <br /> Qwner°s_Signature. Date: ' ' <br /> Last Updated:January 2016 <br />