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' ' � <br /> _ City of Orono �c� � <br /> Suilding Permit Application for Maintenance / Replacement / Remodel 5 ' <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O� Mailing Address: �J�� Permit number:a�` "Q� 7 <br /> O PO Box 66 <br /> Crystal Bay,MN 55323-0066 ��I��� Date received: L�` ��L <br /> / <br /> � � <br /> Street Address: Received by: �� <br /> ti� G� 2750 Kelley Parkway Plan review fee: . 7i <br /> �qkESHn�� Orono,MN 55356 ��� �� vr �� � <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. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ��4q Famwo�d � _ <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 un/ess applicanf demonst�ates su(ficient on-sife parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: S1C0�0► �1�t. <br /> State License# $L Z,S L s Expiration Date: S 3� � <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (t'3Gq-Z2S� (office) QSZ'�17-q 'DOqg <br /> Mailing Address: (� '( L�- City: .Lpyls�q� ZIP:s$!.� 6 <br /> Contact Person: �� a�sp� Applicant is: / Homeowner (Clrcle One) <br /> Email and/or Fax: A O Q$ prA• M <br /> PROPERTY OWNER INFOR TION: <br /> Name: (�� <br /> Phone(day): r - 10- Ha <br /> Address � q� lmwen�l ArfL City:M��� ZIP: SSur� <br /> Email and/or Fax: SCO'r}�AcQ.V�I���.(�OM <br /> PROJECT INFORMATION: Overall ro'ect description: 0.� e.w.o d�e.l �Ad� w��,do� to bedr�w+ <br /> Type of Project: Any earth movement may also require <br /> ❑Door(s) �Remodel ❑Fire Damage <br /> MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage 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) www.minnehahacreek.orp <br /> Estimated Construction Valuation of Project(excluding land) $ 3 <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 altemative 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 i formation,t a lication ma not be issued. <br /> Applicant's Signature: 1�7 Date: ��- �4T(s <br /> � C <br /> Owner's Signatur : a�. ' Date: ��' ����7 <br /> Last Updated:January 2015 <br /> � <br /> I � ���, I <br />