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City of Orono <br /> " � Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> ��A, Mailing Address: ��� �_ <br /> f VO PO Box 66 - Q� Permit number: dC�U a <br /> Crystal Bay, MN 55323-0066�� Date received: /—/ �—/ <br /> Sfreet Address: �f 7�! Receive�:_� 2� `� �'Yl <br /> ____._ <br /> y G� 2750 Kelley Parkway ! ��� pj�n reviewfee• � � <br /> � Orono, MN 55356 <br /> lqkESHO�� I/y�(��lL� - <br /> �''`"' Total Fee: � �9 9� <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: �5 '�v f�r35 �2b .�.l. <br /> Will this be a Parade of Homes, Remodelers Sho e 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. Shutt/e bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT I ORMATIO� � � <br /> Name: ��� �I�I �N s� �d+� . 'SNc . <br /> State License# 5`65�6 Expiration Date: 3 � 31 . ��� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes fhat were constructed prior to 1978 <br /> Phone: (cell) ��Z.-��c� . ��S (office) <br /> Mailing Address: 3 ��� �i�,,,'� �'j'.���, Cit : <br /> 'CKp• ZIP: �53 <br /> Contact Person: Applicant i - -Contractor Homeowner (Circle One) <br /> Email and/or Fax: ��,�.t,.�N L�V�SN �C�v�-� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �g(n�r �-, `�v�uTn �,�J,�.�.— <br /> Phone(day): (,3 . 'g �SS'l <br /> Address: �ggS A � , N , Cit : <br /> Y �ri a o ZIP: t��3 �(o <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 8�permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,cedar 15320 Minnetonka Blvd <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.or4 <br /> Estimated Construction Valuation of Project(excluding land) $ �SS�Svo ' <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 info ati ,the 'cation ma not be issued. <br /> ApplicanYs Signature: Date: � • � Z � 2-� �'� <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />