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<br /> � � 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�O Mailing Address: Permit number: �'��' -C�'��
<br /> PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: � C� %t�
<br /> Street Address: Received by: 'C��
<br /> y �
<br /> �, G� 2750 Kelley Parkway Plan revie e: ' ����'`���� �'� FE -
<br /> t Orono, MN 55356
<br /> �kESH��� � �r ��
<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: (q�/ t-�<�r,�-s S 1�0, .-"� ��a �
<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 sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: i'Z�< < ��:r � �-t�//� s 1�.:.s � J� �_
<br /> State License# ,�� �;��,�i S � Expiration Date: 3 3, _ Zvi�
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) (;,c� ?c i- i'7%� (office) `�>��- -yy� -, �S��
<br /> Mailing Address: , �,� �.�, �t �:�,:< City: �?�(<<�,;, ZIP: �s 3�
<br /> Contact Person: ��,,,, �;�L /(:. 5 Applicant is: �ontracto,l.,/ Homeowner (Circle One)
<br /> Email and/or Fax: �I�P;� .�4, //� s(�cj ,,,,�., ( . c� ,---
<br /> � J
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ��:,�,.; w'1: %/�� -� �..
<br /> Phone (day): —5 - � i � - 3 5�5 3
<br /> Address: _/j�/ �=�. ��.�t,,....;,s �;. � T �� City: C�.�... � ZIP: � S 3l/
<br /> Email and/or Fax:
<br /> PROJECT INFORMATION: Overall project description: f�"`-' f^�''�r h��`��S . ��, ���i (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 /> 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 /> [r�Window(s) in5'J�QI( T�C/41 Y—Sv r--T'� Fax: 952-471-0682
<br /> www.minnehahacreek.ora
<br /> Estimated Construction Valuation of Project (excluding land) $ ��, c u 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 lication ma not be issued.
<br /> ApplicanYs Signature: '��� � �'��� / Date: 7�z` ,� ` � �
<br /> Owner's Signature: Date:
<br /> Last Updated:January 2016 � �� G��( �/�.�C
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