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City of Orono <br /> Building Permit Application for Maintenance/Replacement/Remodel — Residential ONLY <br /> ?. winnows. aoors. siding, re-roof. etc. — NO STRUCTURAL EXPANSION) <br /> Mailing Address: aO/$-(Jo a�/ <br /> Permit number: <br /> o POBox66 <br /> Crystal Bay, MN 55323-0066 Date received: 3-/ <br /> Street Address: Received by: <br /> yF 2750 Kelley Parkway Plan review fee: <br /> Orono, MN 55356 <br /> tfkEs Hov-``" Total Fee: � 1/0' 3 V <br /> gain: 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: 9 r1 �) tV, (A 1 vvt3 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? 0 Yes [allo <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: /"1 c ./(re-CC L_ <br /> State License# /',1 Expiration Date: <br /> Lead Certification Number: it//1- Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (0 l L - a 3'3 - r-3�% (offs e) <br /> •.? . <br /> Mailing Address: ; - �, /� ..�� G Eve/ City: ;z -. o _. (; <br /> Contact Person: &Wt.c. n 7 . Applicant Is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: 2TE�. �' <br /> yl �:' �17�U6..) <br /> PROPERTY OWNER INFORMATION: <br /> Name: ?A c (_. M/ ( C �.. <br /> Phone(day): !L - 7 f 7 -.43 <br /> Address: /S.5 w `cL�rf,A<l -71-41 <br /> City: ci?�.�(i ZIP: S 3G / <br /> Email and/or Fax: [_,'►'l Z ta 1--)6/Y1 <br /> PROJECT INFORMATION: Overall project description: I-A) ✓ LAYS 6 CS 1/1 ski, 5ALS-`ace__ <br /> Type of Project: Any earth movement may also require <br /> -Door(s) Remodel ❑Fire Damage MCWD review&permits: <br /> ❑Re-roof,asphalt ..Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑Re-roof,cedar 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 /> XWindow(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 7 C-Z:O • d 0 <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,q is to annually update our records and records of other governmental agencies required by law. If <br /> you refuse to supply the jpfarmation,the application may not be issued. <br /> Applicant's Signature: Date: <br /> Owner's Signature: � Date: 7/.//6P- <br /> Last Updated:January 2016 <br />