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i �� <br /> . � <br /> City of Orono <br /> B ilding Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> OA, Mailing Address: Permit number: -;/ � C� `� ! d. <br /> � !y PO Box 66 � <br /> � Crystal Bay, MN 55323-OOC6� �� Date received: � � � z� "/� <br /> �� � Street Address: �� �� ����lo Received by: ���� <br /> � 2750 Kelley Parkway ��`� Plan review fee: ��E?Lf.e��� L <br /> � Orono, MN 55356 �' <br /> !1 kFs H��� ,�/ <br /> Total Fee: �p �a� . � <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. (P/ease print) <br /> GE ERAL INFORMATtON: <br /> Jo Site Address: "51 ►5 SusS�.�c ►�oa.dt. �o.+ l.�nc,.� , mrv K 5�5 V <br /> Wil this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> yes,a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service wil/be <br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CO TRACTOR/APPLICANT INFORMATION: <br /> Na e: �'Y1q 'Pi.t-cr�Son <br /> Sta License# �}Lou�,-� o N Expiration Date: 3�3 i/Zo� g <br /> Lea Certification Number: N�yT- 232 i�- 2 Expiration Date: 4/ 22/2ozo <br /> ( r work on homes that were constructed prior to 1978 <br /> Pho e: (cell) (office) (952)�125 -��ts s <br /> MaiingAddress: Gi � � v�loodZd-.�..ic /�..w.wc City: �a2,�-.a. ZIP: ss�l2�i <br /> Con act Person: �or��;r�.,�� Applicant is: ontrac or / Homeowner �c�►�b o�B► <br /> Em il and✓or Fax: <br /> PR PERTY OWNER INFORMATION: <br /> Na e: T�,,,,. �- m o�,rh �r,I mo rc. <br /> Pho e(day): (q52�y73- 0$t S <br /> Add ess: 3tiS Swss<% 2oa.�- City: Lon� Laic.c ZIP: 5535� <br /> Em il and/or Fax: <br /> PR JECT INFORMATION: Overall project description: �� �w�'f ��+ <br /> Typ of Project: Any earth movement may also require <br /> ❑ D or(s) �Remodel ❑ Fire Damage <br /> MCWD review 8�permits: <br /> ❑R -roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑R -roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ R -roof,other(speclfy) ❑Siding ❑Other:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> (�(Window(s) www.minnehahacreek.orq <br /> Esti ated Construction Valuation of Project(excluding land) a_ �O,Ooo <br /> APP ICANT 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 information,the a lication ma not be issued. <br /> �-��r^�— Date: � t �2 i�2 o i� <br /> Applic nt's Signature: � <br /> Owner' Signature: Date: <br /> Last Up ted:January 2016 <br /> I: <br />