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° ~ City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> �i.�. windows, doors, siding, re-roof, etc. — NQ STRUCTUR/iL EX�' ��V) <br /> � Mailing Address: Permit number: _ 5=�� <br /> / ���0 PO Box 66 � <br /> Crystal Bay, MN 55323-0066 �'' Date received: � 3/ � <br /> 1 , <br /> �� � � ; Street Address: � (,..� ✓L�� Received by: v <br /> tiF � 2750 Kelley Parkway �� � ���( Plan review fee: <br /> �,q�,CS-HO�r��' / Orono, MN 55356 � `1� <br /> Total Fee: ���1 l�� <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 returned. (Please print) <br /> GENERAL INFORMATION: J ` /'�, <br /> Job Site Address: 1 (V�°� �� (/�I✓'� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,a specia!event permit is requrred with Po/ice Department and City Counci/approva/60 days prior to the event. Shutt/e bus service wil/be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICA'�IT IN ORLyMLA�N: <br /> Name: K <br /> State License# Expiration Date: �f�iQ(,� 'f�J7Z. <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were consiructed prior to 1978 <br /> Phone: (cell) Z p Z� (office) <br /> Mailing Address: �'J+ �u� Cit : �/{� ZIP: � (j <br /> Contact Person: �}�S� ��,�-�.� , Applicant is: C / Homeowner (Clrcle One) <br /> Email and/or Fax: I�.SSe��,�,g�'��� <br /> PROPERTY OWNER INFORMATION: <br /> Name: � j� � �d11o�2 11�,o�-,s <br /> Phone(day): 7f�3 Z 3�/ 0 Z./(o <br /> Address: Z7q0 Si 1 Ue✓ I/IecJ c�r1V� City: �(��Q ZIP: <br /> Email and/or Fax: �(�,I�ry-�S� Yv�E • Cv � <br /> PROJECT INFORMATION: Overall roject description: WIdCh 0 fl!l'� re Ce a W/i�0�1 C.�7�o�y��� <br /> Type of Project: ny earth movement may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review 8�permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other(speciry) ❑ 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 inforrnation is t a nua update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the infor 'on e cation ma not be issued. <br /> ApplicanYs Signature: Date: �Z�3 1' <br /> Owner's Signature: Date: ��� �' � <br /> �La Updated:Jan ary 2 I /� /� <br /> �/��� � G°(�x �� ( � <br /> / ' <br />