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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� Mailing Address: Permit number: �.�f�o �Q(.)�� � <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: — — <br /> � <br /> Street Address: Received by: <br /> yF � 2750 Kelley Parkway Plan review fee: <br /> �' Orono, MN 55356 <br /> t�kESH�4� • � <br /> Total Fee: 1 I �l , <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: 2 `�f � S ��r�r- �.�;-�.� l �t�t-�Z ���� <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 su�cient on-site parking is availab/e. Non-permitted events wil/not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: S"'� ��S .yn}G <br /> State License# gGCC S i,3-G� Expiration Date: 3 i �o � <br /> Lead Certification Number: �� Expiration Date: —.--� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �, j � ��0 -- ���� (office) ��� � S `��� <br /> Mailing Address: S.r - ,L 8 L�. � � City: �s 8� �L ZIP: S o a5� <br /> Contact Person: �Tj�j,� �( Applicant is: ontractor / Homeowner �c���ie or,e� <br /> Email and/or Fax: c3 �- �/� <br /> 1 t E'-rrr� ��.tne�� S l`�ti � ' C�l^'� <br /> � <br /> PROPERTY OWNER INFORMATION: <br /> Name: S-�'��.1-1 � - LL � �Y'n�c�it <br /> Phone (day): s� ��,3 , c� <br /> Address: �'�7 S� �Q��-- L�.rv 'i,�ra-�`Z �.q..�,.�- City: 6 [.i�►]�L I�1u�IP: S�S 3 S � <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall pro�ect description: �r��`'-� �'o � �c�'c� csw �0�5� ��f}�' <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 /> ❑ Re-roof,cedar 15320 Minnetonka Blvd <br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify�9g- �Other: (speci ) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) � www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ y �� : c� <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 information,the a li 'on ma not be issued. <br /> ApplicanYs Signature: � Date: �/ � 'Z al� <br /> Owner's Signature: ^ Date: C� � � Q ��j <br /> Last Updated:January 2015 <br />