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Oci, 6, 2016 4; O1PM �c, 3086 P. 1 <br /> � , . P1�� C��1 -�� <br /> Ci�y of Orono c-� � n� <br /> Buildin g P��mit A p plication for IIlfaintenance/ Re placement/ Remodel —Resid�ntial QN�Y <br /> �i,�. wir�dows, duors, siding, re-raof, etc.—N�STRUC7URAL EXPAfdSIOP�) <br /> Mailing Addr�ess: �� � � ,�...a „ /�� <br /> ���� Permct n1�mb r <br /> PO Box 66 <br /> Crystal Bay,MN 55323-0066 D.�ie:i'eceive�d � �p <br /> Strsef Address: Received py : <br /> �� ti 2750 Kelley Parkway P��n:,rev�eW f�a <br /> � <br /> � G Orono, MN 55356 . � <br /> �Ksst�o�`�' T�C21 Fee <br /> Msin: 952-249-4600 Fax; 952-2ag-4616 www.ci.orono.mn.us -'x <br /> . . .,,,. ._,. . .. <br /> This app[ication form must be completed in full and all required information must be submittad. <br /> Incomplete applications will be returned. (f'Iease print) <br /> GENERAL INFORMATION: J <br /> Job Site Address: y�� T 1� '`� � <br /> Will this be a parade of Homes,Remodelers ShoWCase Home or other Display Home7 ❑Yes No <br /> If yes,a special event permrt is raqulrvd with Police Depedment and Clty Council approval fi0 days pnor to the event. Shuttle bus service wi0 be <br /> required unless applicant demonstrates sufficlenC on-s,Ye parking rs avaifable. /Von-permitted events wlll not be allowed. <br /> CONTRACTOR/APPLICAN7 INFORMA7 ON: <br /> Name: � -e�. �� <br /> State License# � Expiration Date: <br /> Lead Certificatfon Number� '2 � �- Expiration Date: <br /> (for work on homes that were construcfed prlor to 1978 � _��^ ^� ��c7 <br /> Phone: (ca11) (office� �J 1 i� <br /> Mailing Address: City:� � ZIP� <br /> Contact Person: Y' y-�� Applicant is: ontractvr / Homeownec �c�r��aono� <br /> Email and/or Fax: r' <br /> PROP�RTY OWN INFORMATION: <br /> Name: ((` �� <br /> Phone(day): Q � <br /> Address:. • City: Zlp: <br /> Email and/or Fax� <br /> PROJECT INFORMATION; overall ydect descri tlon: � � � (,�' �� ( � ��� Z- <br /> Type of ProJect: Any earth movement may also requlre � �/1,� <br /> ❑Door(s) �Remodel ❑Fire Damag� MGWp revlew&permits: � <br /> ❑Re-roof,asphalt ❑aepair ❑Storm Damage Minnehaha Creek Watelshed Dlstrict(MCWD) <br /> 15320 Minnetohka Blvd <br /> ❑Re-rooF,cedar [J Restoralion ❑Water Damage Minnetonka, MN 55345 <br /> []Re-roof,other(spec�sy) ❑Siding ❑Qther:(specify) Phona; 952-471-0590 <br /> Fax; 952-471-0682 <br /> ❑Wlndow(s) .minnehahacreek.or <br /> Estlmated Construction Valuation of f'roject(eXcluding land) $ � <br /> APPLICANT ACKNOWL�AG�M�NT: <br /> • Agrees to provide afl information required or requested by the Buflding Depattment; <br /> • Gartifes that fhe informa�ion supplied Is true and correCt to the best oF hislher knowledge. The app{icant recognizes that they are <br /> solely responsible for submitting a comple(e application being aware that upon failure to do so,the staff has no alternatEve bul to <br /> reject it until it is complete; <br /> • 5ome or al1 of the inFormation that you are asked to provfde on this applicatian is classified by State law as either private or <br /> confdential. Prlvale data is information which generally cannot be piven to the public but can be given to the subject of the data. <br /> Confidential data is information which generally cannot be glven t0 eilher the public or the subject of the data. OuP purpose and , <br /> � intended use of thls Information is to annually update our r�cords and records of other governmentai agencies required by law. IF , <br /> ou refuse to su 1 the information th a lication ma not be Issued. . I <br /> Applicant's Signature: i � bate� � <br /> I <br /> Owner's Signature; �ate� �I <br /> Last UptlaCed�January 2018 <br />