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� <br /> . ' <br /> ` � � City of Orono <br /> Building Permit Application for Maintenance/ Replacement/Remodel— Residentiai ONLY <br /> {i.e.windows, doors, siding� re-�oof, etc.—NO STRUCTURAL EXPANSION) <br /> �O A' Maili O�8. Pemut number. 0�0�7 G�l'` <br /> j vO <br /> Crystal Bay,MN 55323-0066 Date received: � / <br /> Street Address: Received by: <br /> s `�` 2750 Kelby Parkway Plan roviewfee: <br /> `� Orono,MN 55358 <br /> �1KESH0�`�' �-� (�1 � <br /> Totai Fee: <br /> Mein: 952-249-4800 Fax: 952-249-4816 www.ci.orono.r�m.us <br /> This applicadon form must be completed in full and all required ir�formation must be submitted. <br /> Incomplete applications wili be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Addr�ess: a� <br /> WIII this be a Parade of Homes,Remodelers howcase Home or other Dfsplay Home? Yea No <br /> H yes,a specid event permit is required witA Pdice DapertmerN and C/ty Coundl approvei a0 daya p►ior to fhe evenf. Shu�tk Dus wii!be <br /> required unbss epplicent demonsbetea sulPicient on-a�e perldng is aveile6le. Nan-permitted events wip not be al/owed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: _�hT�iv'n ,.�.i.,.,,.6L�,� s/�vi�r�Y�-:— LL o <br /> State License# Expiration Date: <br /> Lead Certiflcation Number. Expiration Date: <br /> (f+w woih on harws Lh�t wMn corabuctad prior t�1978 <br /> Pnone: (ce�q � ��-- � �.i 6�� ? (otfice) ��j- L/7���7�, � <br /> Mailing Address: City: ZIP: <br /> �n��Pe��� r_NAQ1�s' fc/i o�nl Applicant is: Contractor Homeow �c+�a.a�.� <br /> Email and/or Fax: �. A Mb �L,��.o p/��L.. c�.;,r� <br /> PROPERTY OWNER INFORMATION: <br /> Name: � s',, �.�.n �u r� S�,,,.��,�-n� �E.,� LG.G <br /> Phone(day): q�S�-�-/ Z I ��_ <br /> Address: c..j�l L9-GCF S T E 1� C�ty� l,tf'3���1'l"/�' ZIP: .S S?�I / <br /> Email and/or Fax: (,,�},�/� �Z..�p n�/!.�L_ �, M <br /> PROJECT INFORMATION: Overall 'ect descri tion: <br /> Typ�of Project: Any earth mowmer�t may also roquire <br /> �.Door(a) f�Remodel ❑ Fire Damage ���nview d�pennits: <br /> �Re-roof,asphalt ❑Repair ❑Stortn Damage Minnehaha Creek Watershed District(AACWD) <br /> 15320 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration gj Water Damefle Minnetonka,MN 55345 <br /> ❑Re-roof,other�sp«�ryr) ❑Sidinp ❑Other.(speciry) Phone: 952-471-0590 <br /> Fax: 952�71-0682 <br /> ❑wndow(s) ' v�y�yv.minnehahacreek,oro <br /> Estimated Conatruction Valuatlon of Project(exduding land) S�tv� �006� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Aflreea to provide all information required or requeated by the Building DepaMiant; <br /> • Certifies that the infoRnation wpplied ia true and coReat to the beat of hia/her knowledpe. The applicaM rocopnizes that thsy are <br /> solely reaponsible for submitting a complete application being aware that upon failure to do so,the staff has no altemative but to <br /> reject it un�l ft is complete; <br /> • Some or all of the inforrnation that you aro saked to provide on this application is Gasaifisd by Stab law as either private or <br /> confidential. Private data is infortnation which generaly cannot be given to the public but can be qiven to the subject of the data. <br /> Confidential data is infortnaaon which genereNy cannot be giv�en to either the pubNc or the subject of the data. Our purpose and <br /> intended use of this information is to annualy updata our recorda and records of olher govemmental agenaes required by law. Ii <br /> ou rofuse to su the information the a ication ma not be iasued. <br /> ApplicanYs Signature: Date: <br /> Owner's Signature: � ' .,,���,Date:�i/�,r/ �_3 •"�o/ 7 <br /> Last Updated:January 2016 <br />