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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 TRUCTURAL EXPANSION) <br /> Mailing Address: <br /> �QN PO Box 66 C�,, p�� Permit number: O� S`"(�(,,,�9 S <br /> 0 Crystal Bay, MN 55323-0066 ��� Date received:` � / <br /> � Street Address: � � �`��� <br /> ��, � 2750 Kelley Parkwa Q�, Plan reviewfee: <br /> �' Orono,MN 55356 <br /> �'�FSNo�`` 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. I� <br /> Incomplete applications will be returned. (P/ease print) �a� �� <br /> GENERAL INFORMATION: � <br /> Job Site Address: �3� S;,�t,f V1K.��d. ., rono MtJ tJ53�b <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other D�play Home? Yes No <br /> If yes,a specia!everrt permit is nequired with Police Department and City Council approval 60 days prior to the everrt. Shutt/e bus sernce will be <br /> requiied unless applicant demonshates suflScieM on-site parkiny is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/AP LICAN FORMATION: <br /> Name: , � � , <br /> State License# G p Expiration Date: 3 3� 2p�(o <br /> Lead Certification Number: Expiration Date: <br /> (for woNc on homes Urat wene constructed prior to 1978 <br /> Phone: (cell) b12- (v85-O�o� (o�ce) qrj2- �I�S- 205� <br /> Mailing Address: n City: ;n,��,.}y��� ziP: ��3y5 <br /> Contact Person: � Applicant is: ontracto / Homeowner �c��c�e o�� <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �,1�t,-E vU� �Ir10✓►3�n <br /> Phone(day): 12- U. <br /> Address: 2�?� S;I�c�u�t� a. c�ty: �ronv ziP: 5535{� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: ���ve.r• vv+adu. <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review�permits: <br /> � Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑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 /> Confident��a#a-' ' which enera cannot be given to either the public or the subject of the data. Our purpose and <br /> intended`use of this 'nformati is t nnuall upda ur records and records of other qOvernmental agencie required by law. If <br /> ou refuse to orm 'o t e a atiom m �ot be issued. � ✓ <br /> ApplicanYs Signature: Date: � <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />