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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.�. �rvindavvs� dc�ars, s�a��g, rE-rc�c��; �tc. — NCJ STRUC�IJ�AL EXPA�ISIC?N) <br /> � O�r MailingAddress: Permit number. �b/S -� �j� <br /> �- �V� PO Box 66 <br /> Crystal Bay, MN 55323-0066� � Date received: <br /> \ <br /> Sfreet Address: � ,��� Received by: <br /> � � 2750 Kelle Parkwa <br /> ' ` Y Y � Plan review fee: <br /> ��t ` � Orono, MN 55356 <br /> qk�sE�o�� .. <br /> Total Fee: �d�. �5' <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 /> JobSiteAddress: ( �.. '�'j l �1p�(L. �'r 02.�y.JO M� ��39 ( <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 wi//be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/AP LICANT INFORMATION: <br /> Name: b� J� c�o�Er-S �.�L <br /> State License# � (Qa,q �ps Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell)�'S Z- �5�. - � � (office) � ?�3. 7 ( ?- `�p� <br /> Mailing Address: , o D (p $ �.,op.d�Cp /Yl� s"S?S�� City: ZIP: �' 7 <br /> Contact Person: �pt�E M p�� Applicant is: C n ractor Homeowner (CircleOne) <br /> Email and/or Fax: ��� Ro-ytCp.e,E,k�i���octiS • c o� <br /> PROPERTY OWN INFORMATION: /� <br /> Name: �Wr��. ra,►.)c� ��lA-� � � fT�c,J g <br /> Phone(day): (°p� 2... '� �� - 3 er f <br /> Address: f 1.9 � (�j2..'n,� �� • City: DGZ,a�J• ZIP: S� 3�'� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall ro�ect description: ��F�v4n�M � Z``� <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) ww�v minnehahacreeko�� <br /> Estimated Construction Valuation of Project(excluding land) $ • <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 /> ou refuse to su I the informati , e a I' tion ma not b issued. <br /> ApplicanYs Signature: Date: � � � �� <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />