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City of Orono
<br /> Building Permit Application for Maintenance / Replacement/ Remodel — Residential ONLY
<br /> (i.e. wi,: . Joars �e-raof, etc. — fV0 STRUCTUFZAL E�,
<br /> �O�O Mailing Address: Permit number. -� lv -� � �
<br /> PO Box 66
<br /> Crystal Bay, MN 55323- �1 Date received: _ I—
<br /> Street Address: � Received by: �
<br /> �. G� 2750 Kelley Parkway �'� Plan review f : `' � s't't"G� `�
<br /> `�tq �, Orono, MN 55356 V �
<br /> kES H�� Total Fee: � !��p�, � 7
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us r
<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: ,�.1� 5 r a�J �a l„�v� ��
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes -Nd
<br /> If yes,a specia/event permit is required with Po/ice Department and City Council approval 60 days prior to the event. Shuttle bus service wil/be
<br /> required un/ess app/icant demonstrates sufficient on-site parking is avai/a6/e. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPL CANT INFORM�ATION:
<br /> Name: �,��,�-� , ' )R��•-�
<br /> State License# Expiration Date:
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) � ��. ' �� 1-- y p��; (office) (�,i�,' ��� - ��l`� �
<br /> Mailing Address: �c� � ��,�,���� ��� �� City: ���,.��, � 3�
<br /> Contact Person: ,I(c ��,r,� , .. Applicant is: Contractor / Homeowner (Circle One)
<br /> Email and/or Fax: �q,�� ►�•o z`,�i C �.�n r���, � i;;r.•.
<br /> PROPERTY OWNER INFORM��TIk�: � a rr��
<br /> Name: I� �. , )�..,�,�.J
<br /> Phone(day): S��-�XI�-�eo�� � 6��- �3� - �c�i �
<br /> Address: a�y; ��c,�H l�,k r p City: ���..,.� ZIP: •�3�-� (
<br /> Email and/or Fax: � ���,,,�����,,L G��,�, .�;,.....
<br /> U��qTlr� K.F��.� � � s.�Tl� �j/►T Ik�4.cV^"' �r ��t 1
<br /> PROJECT INFORMATION: Overall project description:
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) [�2emodel ❑ 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(speciiy) ❑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) $
<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,th lication ma not be issued.
<br /> `� `'� d-'l
<br /> ApplicanYs Signature� ----••�-- Date:
<br /> Owner's Signature: , � - Date: �'
<br /> Last Updated:January 2016
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