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� .. <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O ` O Mailing Address: Permit number: �Q� <br /> �j PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: ` <br /> Street Address: Received by: <br /> y G� 2750 Kelley Parkway Plan review fee: <br /> `� Orono, MN 55356 <br /> 1qk�SH��� 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, Remodelers Showcase Home or other Display Home? ❑Yes ❑ No <br /> /f yes, a specia/event permit is required with Police Department and City Counci/approva/60 days prior to the event. Shuttle bus service wi//be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: , <br /> Name: T�t.o %e�iG�1�L�� �o �15i/��CU� �/� l� <br /> State License# � L;; 7 ��c� Expiration Date: /���,,;-� � <br /> Lead Certification Number: �� Expiration Date: <br /> (for work on homes that wer�constructed prior fo 1978 <br /> Phone: (cell) �/� �-��� -- 2 j� � (office) <br /> MailingAddress: "7s✓�, ��.-` �/` City: �✓✓,� ZIP: S� y <br /> Contact Person: �`r� �yj�SC��" Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: � �-- <br /> PROPERTY OWNER INFORMATION: �, <br /> Name: '} �� �D G�- <br /> Phone (day): S .- y7� — ��S-(o � i <br /> Address: f 3p� S�/v��_ fJ�GtL �-- City: C=X7�"�� ZIP: 5�3��/ <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> �loorfs)_ ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> �R - ,�phalt ❑ 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.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 information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the infor a ' nA the a lication ma not be issued. <br /> ApplicanYs Signature: �� Date: � —/c/ � �. S <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />