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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 /> �O�O Mailing Addr�ss: Permit number: — �L
<br /> PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: /Z" �`�
<br /> Street Address: Received by:
<br /> � � 2750 Kelle Parkwa
<br /> y�, G� Y Y Plan review fee:
<br /> � /
<br /> Orono, MN 55356 ��, /� 1�
<br /> �kESH04 ' Total Fee: �T �
<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: � 'J � S� �"��� - l,
<br /> Will this be a Parade of Homes, Remodel�rs Showcase Home or other Display Home? ❑ Yes ' No
<br /> If yes, a specia/event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will be
<br /> required un/ess applicant demonstrates su�cient on-site parking is availab/e. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATIQN: ,.
<br /> r� �(� ,� ,
<br /> Name: �- � � �'�,���--� � Gc�� '�� �� � ��� ����'
<br /> .,
<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 � �� �'��� � ( )
<br /> ( ) r= �. ;�� � ��i �' 7 office
<br /> �
<br /> Mailing Address: - (�:C J �,f-��, ���i City: ;'�� �1� .s - � ZIP: ir` �,�,�
<br /> Contact Person: � „�z�___. Applicant i : Contract r / Homeowner (Circle One)
<br /> Email andbr Fax: { ,-- ,` `, ,^� �. j J <<. ,,� 1 _ ___-�
<br /> �-% ! . �",'e�,_.�-,�-, G'� ✓�- _i-,l`W �ti�J
<br /> ,'
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �;1�- ��` __.: %1�., L
<br /> Phone (day): `
<br /> Address: P. ' r � CitY: '� it�;��,J ZIP: „ � �j
<br /> �
<br /> Email and/or Fax:
<br /> PROJECT INFORMATION: Overall pro'ect description:
<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 /> 15320 Minnetonka Blvd
<br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345
<br /> ❑ Re-roof, other(specify) � Sidin � ❑ Other: (specify) Phone: 952-471-0590
<br /> 9 �c3.°- r;
<br /> Fax: 952-471-0682
<br /> ❑Window(s) i� www.minnehahacreek.orq
<br /> Estimated Construction Valuation of Project(excluding land) $ � �r�J
<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 tq�nnually update our records and records of other governmental agencies required by law. If
<br /> ou refuse t su I the informa�ion, the a lication ma not be issued.
<br /> ApplicanYs Signature: -�"` � �� Date:
<br /> Owner's Signature: Date:
<br /> Last Updated:January 2015
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