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. . �> �;� � , � �> <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement/ Remodel — Residential ONLY <br /> (E.e. �ir���L���, dr,o��, siding, �t-roofi, et�. — NC1 ��RUCTURAL EX�'�l�SiON) <br /> �O� Mailing Address: �v� 7 ��� -' - / <br /> PO Box 66 Permit number: � �_ <br /> 0 Crystal Bay, MN 55323-0066�, Date received: � U -1 � � � <br /> I t ,I j Received by: �F <br /> � � Street Address: �, p' t� �;; ; <br /> �`y�, � 2750 Kelle y Parkwa y� /� ;;�i ' P l a n r e v i e w f e e: /• �� <br /> � � Orono, MN 55356 � <br /> qKfSH��� <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 returned. (Please print) <br /> GENERAL INFORMATION: � � � / � <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodeler Showc� Home 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 service will be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP ANT IN RMr TION: <br /> Name: _,���7�'�l'/P����� �y!`7`, ��c <br /> State License# � 3c// G�L Expiration Date: Zp�� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �/Z- 3 _ 7 (office) <br /> Mailing Address: Z1,// /��,/ � ,�� �" City: �; � ZIP: SS.3/ <br /> Contact Person: Applicant is: Cont_ ractor / Homeowner (Circle One) <br /> Email and/or Fax: � , � � <br /> PROPERTY OWNER INFORMATION: <br /> Name: v 4 �,�., � t � <br /> Phone (day): �2 J � �� � <br /> Address: 3�� s'�.^„-,c ; � City: r�y�� ZIP: <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.minnenahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ Z 3.� <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 altemative 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 1 the information,the a lication ma not be issued. <br /> ApplicanYs Signature: /� . �L�.dL.t,�:.� Date: IC� � ��- �� <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />