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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O ` _ MailingAddress: Permit number: p�O� � �97 <br /> l��O PO Box 66 I <br /> Crystal Bay, MN 55323-006� � Date received: �—� "l� <br /> Street Address: L� Received by: <br /> y�, � 2750 Kelley Parkway � Plan review fee: <br /> L Orono, MN 55356 <br /> tqkESH�4� <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. (Please print) <br /> GENERAL INFORMATION: /- ,�)� � <br /> Job Site Address: � f�rC% :�.�.� ��c��-� x,�� C�i E�<'�Ci' t-ti% <br /> Will this be a Parade of Homes, Remodelers S owcase 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 servic will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP CAI�T INFORMATION: <br /> Name: ��- <br /> State License# �' �Q Expiration Date: y' <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were consfructed prior to 1978 <br /> Phone: (cell) ��j �- z�'�p- ���'� (office) <br /> Mailing Address: 2� ' �i,. r� �� City: � ZIP: 7 j 3 /�j' <br /> Contact Person: /G c� �'..- Applicant is: ortt c or Homeowner (CircleOne) <br /> Email and/or Fax: ��? ,e;,.o� K ,�, <br /> PROPERTY OWNER INFORMATION: , <br /> Name: j�Gt cJe .a- .,J�CS�c� U�,�-����f't�✓ <br /> Phone (day): <br /> Address: �'�� �S��l.� � City: �z�-� ZIP: <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 8�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) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.ora <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 �nformation is to annually pdate our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the inform t' ,the a tion ma not be issued. <br /> Applicant's Signature: t-� Date: �� ��i/ � <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />