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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 EXPANS(ON) 11 <br /> QMailing Address: Permit number: l r <br /> A'O PO Box 66 <br /> Crystal Bay,MN 5632MO66 Date received: d'7- (P <br /> 5tmot Addtcss: Received by: <br /> 2750 Kelley Parkway / <br /> '• Y Y Plan review fee: <br /> �rq �G� Orono.MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249616 www.ci.erono.mn.us <br /> This application form must be completed in full and all required information must be su Ittod. ��/b <br /> Incomplete applications will be returned. (Please print) , t[I2 <br /> GENERAL INFORMATIO <br /> Job Site Address: M L(Gt��C'�� � �1'�'.-6�......!_! -0-yes_Q <br /> Will this be a Parado of Homos,Relmodelers Showcase Home or other Display Home? 0]Yes �,�1 <br /> N yos.a special event pormlt is required with Police Department and C/fy Coanci/approval 60 days prior to the event. Shuttle bus so ice wf11 he <br /> Avquired unlass applicant dornonstratos sufficient onsito pork/ng is available. Non permitted ovonfs will not be allowed, <br /> CONTRACTOR/AP UCANT INFORMATION: LL(- <br /> Name: vo I <br /> State License# Expiration Dale: <br /> Lead Certification Number: Expiration Date: _ <br /> (for work on homes that were constructed prior to 9978 ()J& V)Z--7 -7-9 3ZZ �y <br /> Phone: (cell) (office) <br /> Mailing Address: VtwIgn e City: _ <br /> Contact Person: e, "Gy"1 Applicant is: Contractor / Homeowner la ono) <br /> Email and/or Fax: Gj ' <br /> PROPERTY OWNER IV f ORMATION: <br /> Name: <br /> Phone(day): p <br /> Address: '�j �(Q� '�1/��iUJ G /I\V :..� City, 116no ZIP: C� 72(04 <br /> Email and/or Fax: el l^lA✓_U2 M 01 <br /> PROJECT INFORMATION: Overall project description: _ <br /> Type of Project: Any earth movement may also require <br /> *oor(s) ❑Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt Repair ❑Storm Damage Minnehaha Crock Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑Re-roof,coder ❑Restoration ❑Water Damage Minnetonka,MN 55345 <br /> ❑Re-roof,other(speoity) (.Siding ❑Other:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> W indow(s) www.minnehahacreek.orr- <br /> Estimated Construction Valuation of Project(excluding land) $ T <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrocs 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 knowlodgo- The applicant recognizes that they are <br /> sololy responsible for submitting a complete application being aware that upon failure to do so,the staff has no altemative but to <br /> rojoct it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by Stato law as either private or <br /> confidontial. Private data is information which gonerally cannot be given to the public but can be given to the subjoct of the data. <br /> Confidential data is information which gonerally 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 requirod by law- If <br /> you refuse to supply e inform n,the application may not be issued. _ _ <br /> 2/7�_ <br /> Applicant's Signature' /v ✓ Date: 7 At <br /> Owner's Signatur�`/�- Date: <br /> Last Updated;January 2016 <br /> 1 'd 2901*L*296 ut.100 d A-IWW <br />