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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 /> A, Mailing Address: Permit number: 2 I SG <br /> ��l U VO PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: L/ — <br /> - Street Address: Received by: <br /> tiF G� 2750 Kelley Parkway Plan review fee: <br /> lg <br /> kf S H OOrono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us v,l< -to )CIWA-L, 6"LA1 �. <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: 4-� S <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? El Yes o <br /> ff yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle 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 INFORMATION: <br /> Name: t n`� , � s k- � � <br /> State License# Ti-, i XL_41�xpk4tion Date: <br /> Lead Certification Number: ViLExpiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (circle one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: N1 f�,G�f- 2( �_ <br /> A <br /> Phone(day): j --7 a'Q — 3a--I <br /> Address: -TG t,4y- rZ1\17 City: E fbu ZIP: S <br /> Email and/or Fax: (-A �tcl-1S1 Corn <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven,MN 55391 <br /> ❑ Re-roof,other(specify) [I Siding ❑Other: (specify) Phone: 952-471-0590 <br /> � Fax: 952-471-0682 <br /> ElWindow(s) f� YY Fax: <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 /> you refuse to supply the infbrmationA the application may not be issued. <br /> Applicant's Signature: AJ"` Date: ULf- I <br /> Owner's Signature: ', Date: 0 (� <br /> Last Updated:January 2015 <br />