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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 STRUCTURAL EXPANSION) <br /> �T MailingAdd�ss: Permit number: � <br /> ���VO PO Box 66 ���S�_C�s� ` <br /> Crystal Bay, MN 55323-0066 Date received: / Z—� �/S <br /> Street Address: Received by: �c;-`-� <br /> � _ <br /> 6�, ,� 2750 Kelley Parkway Plan review fee: `� <br /> t,� �,�' Orono, MN 55356 <br /> '�ESH�� • <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: ��p'� 5c�c�a�f (,(',:��,� 17�t� <br /> Will this be a Parade of Homes, Remodelers howcase Home or other Display Home? Yes -�.No <br /> If yes, a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will be <br /> required un/ess applicant demonstrates su�cient on-site parking is available. Non permitted events wil/not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: / ` <br /> ��.�u�i.� C��'J.7_S L�o� <br /> State License# �� y S�3 �� Expiration Date: ��� <br /> Lead Certification Num er: ,U�T- SY:2 0� - I Expiration Date: <br /> (for work on homes that were constructed prior t 1978 <br /> Phone: (cell) ��2,-�p y - s�'�� (office) �� Z- _ <br /> MailingAddress: Calde a e City: C��,,( �,,t QI� ZIP: S�Sy�Z,., <br /> Contact Person: l e��t e Applicant is: Co ct / Home wner (Circle One) <br /> Email and/or Fax: � yy� ��-k �; C,row.� v►^✓� , G� v�,� <br /> PROPERTY OWNER INFORMATION: <br /> Name: ,4 e 1 c=� l�K�uv�p� <br /> Phone (day): �1 - ���_�o?p <br /> Address: �Zjv� S� 4� � r;� City: p,��v,Z� ZIP: <br /> Email and/or Fax: �o,,,.Q � c e��c.�, S . c� <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 Minnehah�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) � � - ti�� S � �c.� www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ �U — <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 tio ,t e a lication ma not be issued. <br /> ApplicanYs Signature: Date: ��- c`� �--�� 3— <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />