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, � City of Orono <br /> �Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �T Mailing Address: 5 _��� <br /> ��l VO PO Box 66 Permit number: ZO r <br /> Crystal Bay, MN 55323-0066 Date received: � �o � <br /> Street Address: Received by: �- � `/ J <br /> �l G� 2750 Kelley Parkway Plan review fee: fu� -f-a.[�.c... .. <br /> Orono, MN 55356 <br /> 9'�ESH��� LLcV(.�'�Cu( dt.� ..:r. : . <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 /> �',�. 1����'��`�`�t��'Z�'�'��' Incomplete application will be returned. (Please print)- <br /> GENERALINFORMATION�4a3 � <br /> Job Site Address: � � �� � -��//h�-� ��"� u -�._ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes + i�r <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shutt/e bus s �ic will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP �ANT INFORM N: <br /> Name: � �,, �.� � �� ��-�� <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that wef e constructgd prior to 1978 <br /> Phone: (cell) (� �Z - � �'/ —�Ll� (office) <br /> Mailing Address: . U � .� „, �,�,�,� , City: V v��-. ZIP: <br /> S <br /> Contact Person: � Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: `,� . J �� 1 , ,� �4 , '� s �v ,�� <br /> PROPERTY OWNER INFOR�ARA�TIqN� r�� /"'� <br /> Name: %{ (, (. �/ <br /> Phone(day): /Z _ '7�C� — -Z <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall ro�ect descri tion: `l�.�-c%�-%"�b1 G'��'t,�'�"� � ' � � <br /> P 1 p a�. ..�d�. L�J Cti.l�S � I4��v��t <br /> T• of Project: Any earth 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(MCWD) / <br /> ❑ Re-roof,cedar 15320 Minnetonka Blvd r� <br /> ❑ 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) $ s� <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 app►ication 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�e.�,ner ly cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this info a' n is o�nn Ily update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I i ormatio ,th a lication ma not be issued. <br /> ApplicanYs Signature: Date: � �v � � <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />