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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 /> �0 Mailing Address: Permit number: �J — <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 ��Q 1 J Date received: <br /> Street Address: v� D, Received by: <br /> y ` 2750 Kelley Parkway 1 v Plan review feeY <br /> ld'rESHOOrono, MN 55356 Y <br /> �� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us I <br /> Total Fee: <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. Please print) �i�-��5� <br /> GENERAL INFORMATION: j /e7o f 1 X <br /> Job Site Address: `'( --�- -vVI ;U <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? LJ 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/APPLI NT INFORMATI9.N: <br /> Name: (�Wv\�_O <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes thatwer constructed prior to 1978 <br /> Phone: (cell) p IZ 61 (office) <br /> Mailing Address: C. (j r }r, _Pej City: -0-YN 6 ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: j. <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: C)� <br /> Type of Project: Any earth movement may also re ire �rJ <br /> ❑ Door(s) _Ef&model El Fire Damage MCWD review&permits: <br /> F] Re-roof, asphalt Repair Storm Damage Minnehaha 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) www.minnehahacreek.ong <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 information,tapplicition may not,be issued. <br /> Applicant's Signature: Date: 7K. <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />