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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 EXPANSION) G <br /> V.„..046,..‘ <br /> O� Mailing Address: Permit number: /p— O?)$I <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 3-1 .3-1 g <br /> Street Address: :: ee: <br /> -2750 Kelley Parkway 7• tP d <br /> �l,9KFSH0�� Orono, MN 55356 ~ l4 \ i910` 00 R� <br /> Total Fee: <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 bebmitted. <br /> Incomplete applications will be returned. (Please print) ' / 40). / <br /> q,a2) <br /> GENERAL INFORMATION: + ,• ,, � <br /> Job Site Address: w ,c� R8 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes . 3JNo <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/APP CANT INFORMATION: <br /> Name: �-e' - - LrtA Conck., i%do <br /> State License# Q C(0 6 c6‘ e o Expiration Date: <br /> Lead Certification Number: Ai o0— I I y /i y - a Expiration Date: <br /> (for work on homes that were constructedprior to 1978 <br /> Phone: (cell) _763 -at b , 1 3 30 (office) <br /> Mailing Address: , f t, / A r City , , 4.,(o ZIP: CS-3 I <br /> Contact Person: k iii; Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: �\ ` <br /> rt ,.erc,. roti,S-t- (\) . iaN QUI , ( O <br /> PROPERTY OWNER INFORMATION: <br /> Name: _Gc yh 1 ,�c.\//r� k �e.i- 1 <br /> Phone (day): <br /> Address: S 0._ r, d(N.‘tpc 5 City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: 3.0e 14,,C..1A A- -'-t r‘Clr1 <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) Remodel Fire Damage MCWD review&permits: <br /> o Re-roof,asphalt 0 Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar <br /> 0 Restoration 0 Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) 0 Siding 0 Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> 0 Window(s) YcNiekt..els I1. www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 16S , 000. 00 <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 enerally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this informati n is annually update our records and records of other governmental agencies required by law. If <br /> you refuse to supply the inf a' n,th application may not be issued. <br /> riltietitoee <br /> Applicant's Signature: Date: 3/13/1?) <br /> Owner's Signature: Date: MAR m18 <br /> Last Updated:January 2016 CITY OF ORONO <br />