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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) <br /> *._OAT Mailing Address:PO Box 66 Permit number: y(G/ -0 g 1-)Crysttal Bay, MN 55323-0066 Date received:Street Address: Received by:>, 2750 Kelley Parkway � Plan review fee: 1-0 h Orono, MN 55356 ���///��n, dc I$ <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 be submitted. � <br /> Incomplete applications will be returned. (Please print) ��``//���� `1 1� <br /> GENERAL INFORMATION: <br /> Job Site Address: //EC) (Ali/ G j) l4ua.s t- 7724.,, ( <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes 1,81.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 I APPLICANT INFORMATION: <br /> Name: C—nr 4 S+;4•v5 / 2ND. <br /> State License# 3�, j Expiration Date: inRR,Ch o?o/y <br /> Lead Certification Number: -71604 . Expiration Date: ts4 (v e?n o <br /> (for work on homes that were constructed prior to 1978 1 <br /> Phone: (cell) (D/) , yct°, 18 17 (office) C'Sa , 1170• aoo <br /> Mailing Address: 14 p4,214 R City: no hisseco ZIP: 5 6-3 1-7 <br /> Contact Person: Applicant is: ontracto / Homeowner (Circle One) <br /> Email and/or Fax: Gh4-d ®GhAf:As,s L. Cc' M <br /> PROPERTY OWNER INFORMATION: <br /> Name: T5NAN t- 5 4,4-ell <br /> 'R✓.t-);%Sery <br /> Phone (day): <br /> Address: // �; t1 khket+' 772A.t City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> MCWD review&permits: <br /> ElDoor(s) %Remodel CIFire Damage <br /> El Re-roof,asphalt El Repair [11 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar El Restoration ❑Water Damage Minnetonka, MN 55345 <br /> 111 Re-roof, other(specify) ❑ Siding IDOther: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ y 11 <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,the application may not be issued. <br /> Applicant's Signature Date: 9,''026-'-/(s <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />