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, � City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> �i.�. wir����r�, dc�ar�, �ic����, ������s��, ���. -- �� ��'����"1���� ���������) <br /> /�O ;\ Mailing Address: Permit number: �l U � <br /> 1�1� PO Box 66 � � `� <br /> � � � Crystal Bay, MN 55323-0066 Date received: <br /> � � Received by: <br /> Street Address: <br /> � � �` ��� ` 2750 Kelle Parkwa <br /> �� '`� � Y Y Plan review fee: <br /> �`� �'� � Orono, MN 55356 <br /> �k�st���t ! <br /> � Total Fee: � � 9 J <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us l <br /> This application form must be completed in full and all required information must b submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �jC1o� � +���, ���v� 1� � �,�.�-Z�--,r� , VV�,�% �s� ` <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Dis Home? ' ❑ Yes No <br /> If yes, a specia/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/AP LICANT INFOR ATION: <br /> Name: _ vw�v� °��-e��J�2� <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were consfructed prior to 1978 <br /> Phone: (cell) 3� _ :�R3_�`l3� (office) <br /> Mailing Address: a5ta3 �,� 3� City:�� lp ZIP: s <br /> Contact Person: v�,,�� w;�.e��k�_Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: �, �,�,� � � p� � , (;pyy� <br /> PROPERTY OWNER INFORMATION: <br /> Name: _�;,,�_ `� �,`� `' `� \v���,,-�zx-����2�-� <br /> � � �-��-� �. +�=��� 5 <br /> Phone (day): (Q�a._ l�« - '7`�-7C.� <br /> Address: ��` �,y��Q �..� �_ City:��Z�� ZIP: �53� � <br /> Email and/or Fax: ��`��.ko`�����.��,�.�� �` a � <br /> PROJECT INFORMATION: Overall project 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) ❑ Siding � ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project (excluding land) $ �. �� . 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 lication ma not be issued. <br /> ApplicanYs Signature: �\ � ���r.(�-U��e�..� Date: 9l G[' �(Co <br /> Owner's Signature: ���D ����c:,�� -��a�.� Date: `�l� �� <br /> �st Updated:January 2016 <br />