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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 /> *A/0 Mailing Address: Permit number: / <br /> PO Box 66 <br /> �' )� Crystal Bay, MN 55323-0066 Date received: 9'/8'/7 <br /> q <br /> Street Address: Received by: m F <br /> y 2750 Kelley Parkway Plan review fee: <br /> Orono, MN 55356H0 [�/ <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) <br /> GENERAL INFORMATION: <br /> Job Site Address: 1 0 t DAZTN t u) 1)e K-- <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/A PLICANT INF RMATION: <br /> Name: 3V eti/zl�� Ct/viCi/ca) Salle-ES <br /> State License# 1723 Expiration Date: 3/ 43 <br /> Lead Certification Number': 4(4 i-t- 2_ Expiration Date: lr 20 20 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) 4 �ry Ct �(��'/ (office) 7( 4z4. q434 <br /> Mailing Address: 7 g E 1 (� City: th,_ ZIP: 36,41 <br /> Contact Person: fy 'g /f4i..t ( Applicant is: ontra for / Homeowner (Circle One) <br /> Email and/or Fax: 16 Ht./ /"'e/ etAAL; <br /> PROPERTY OWNER INFORMATION: <br /> Name: pjiE. <br /> Phone(day): 962, 4 3 .11,Address: /(92.6, 4/1rjy -/.1 u91 itOtt—) City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: 41- 24) 14ed <br /> Type of Project: Any earth movement may also require <br /> 1=1 Door(s) El Remodel 1=1 Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt 1=1 Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration Water Damage Minnetonka, MN 55345 <br /> 1=1 Re-roof,other(specify) 111Siding 111Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ /4" 7cro <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 t information the applicati/ n may not be issued. <br /> Applicant's Signature: t 7 Date: / ff7ef/7 <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />