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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 /> A(2 Mailing Address: :::::: <br /> : ,c5 -vb 790 <br /> AD x66MN 55323-0066 6-9'/S <br /> Street Address: Received by: /WP-.y L 2750 Kelley Parkway Plan review fee: <br /> t Orono, MN 55356 <br /> �'�FSHO� 42.7 <br /> Total Fee: / CCU <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: 24 q5 c)000I4AV& Q(I VE <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes KNo <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: <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: (' <br /> Name: (h Nalk (OLT <br /> Phone (day): C t t to7-312 <br /> Address: /J{8s' 44100NAMe-,J City: (.O,JC i.AMc( ZIP:4 , .7 3s <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) Remodel ❑ Fire Damage <br /> MCWD review&permits: <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration 0 Water Damage Minnetonka, MN 55345 <br /> 1:1 Re-roof,other(specify) 0 Siding ❑ Other:(specify) Phone: 952-471-0590 <br /> edi Fax: 952-471-0682 <br /> ❑Window(s) FI�IIN (taco) to www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 7 OG.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 general) cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annual) pdate our records and records of other governmental agencies required by law. If <br /> you refuse to supply the informa i e a ation may not be issued. <br /> Applicant's Signature: G✓ �✓ Date: at- 07 1 <br /> Owner's Signature: Date: of-o9-iS <br /> Last Updated:January 2015 <br />