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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 /> �QqrO RECEIV ailingAddress: Permitnumber: –�� � <br /> � y PO Box 66 'n <br /> i <br /> � SEP 2 9 201� Crystal Bay, MN 5532�-�- �(/� Date received: 'e2.�1—/ <br /> I C /� Received by: <br /> � h 1 Street Address: O <br /> y`��,, ���% CffY OF ORONO 2�50 Kelley Parkway � Plan review fee� <br /> Orono, MN 55356 Total Fee: �� � �l �o <br /> kESH� ti` <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: � �-� j � ��}C7�F/U�`�S ��,�; � �c,k-�;� . _ <br /> Will this be a Parade of Homes, Remodelers Sho case Home or other Display Home? ❑ Yes _ o <br /> If yes,a specia/event permit is required with Police Department and City Council approva/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: J ��li/�`' � T�/P11 i1JC l, �- C� <br /> State License# �L �3U�� c.E Expiration Date: 3 �,� 2�� �j <br /> Lead Certification Number: � G��� �$�; (�- Expiration Date: <br /> � <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (p�Z- '�Vz� ��j�t�z� (office) S�� <br /> MailingAddress: �,CS �f� S�IR��- i.v C�tY � ,r�� o,v ZIP: � Si/7 <br /> Contact Person: �'/fi�v � ��� Applicant is: Contracto Homeowner (Circle One) <br /> Email and/or Fax: �q:r c�J e ' :: i( �C G C�-e� ; �o�►^- <br /> PROPERTY OWNER INFORMATION: <br /> Name: "�/f�;i.k S �f� 0 R-S <br /> Phone (day): Cr,I Z'�'�{.(� '— S'�(o� <br /> Address: Cit : ZIP: <br /> S�Yr� GS ��� �r Y <br /> Email and/or Fax: j LrpC �S�aL c� ���S � CC f'�- <br /> � <br /> PROJECT INFORMATtON: Overall project description: s E'L? �- �'���� <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) f�'Remodel ❑ Fire Damage <br /> 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) $ / �F S; Ofl0 ; �c' <br /> APPLICANT ACKNOWLEDGEMENT: <br /> --------------------- ---- ----- -- — —---. <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 inf ation,the a lication ma not be issued. <br /> .� • <br /> ApplicanYs Signature: - ` Date: �� 2� / <br /> � <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />