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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: <br /> �Of VO PO Box 66 ( ✓' <br /> Crystal Bay, MN 55323-0066 ft4l Date received: ! <br /> 'L 44 <br /> Street Address: CV' ,� Received by: <br /> y G� 2750 Kelley Parkway ` Plan review fee: <br /> t <br /> kES HO Orono, MN 55356 <br /> g � <br /> Total Fee: i <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: 1cj2l�) *T)Q4A\LJN Zo <br /> Will this be a Parade of Homes, Remodelers Showcase 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. 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: \SloO LLC <br /> State License# Expiration Date: 3 i I <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructe prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: J 62D LAS 21-9-rl_ L=_4Sr- City: ,ip -Z-A•jA ZIP: <br /> Contact Person: Applicant is: n rac or / Homeowner (Circle One) <br /> Email and/or Fax: j��f 1�1 t✓. �ZC1Slc1 Mr.I ,(,CM <br /> PROPERTY OWNER INFORMATION: <br /> Name: -!UC-�4 (16-IL-St7tJ <br /> Phone (day): -2s -3l1}q <br /> Address: \CLS City: d12CN�o ZIP: w-�S3�(si <br /> Email and/or Fax: OE�ij e- rN,i4sL cc s <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) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacree .or <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 an ally update our records and records of other governmental agencies required by law. If <br /> you refuse to supply the inJQPKhatiQjm, e aDpli2gion may not be issued. <br /> Applicant's Signature,- Date: <br /> Owner's Signature: Date: l �l <br /> Last Updated:January 2015 Afo <br /> }�►Gi ( ��� <br />