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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e..windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION (� <br /> � � <br /> ��O� Mailing Address: Permit number: � P <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: � 6 � <br /> � � Street Address: Received by: <br /> ti�, G� 2750 Kelley Parkway Plan review fee: � <br /> lqKFSH��� Orono, MN 55356 p� K � �5 S-�„� M� p� � <br /> Total Fee: � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �2 r�^'/�'�— �(�, ��.Q <br /> This application form must be completed in full and all required information must be submitted. O(� • <br /> Incomplete applications will be returned. (Please print) �j ��� <br /> GENERAL INFORMATION: <br /> Job Site Address: ��S �u,��- �f�,.� �tp�;,,�, , Q;o,•�v i`�� SS�;�,3 <br /> Will this be a Parade of Homes, Remodelers Showcase Home o other D splay Home? ❑ Yes ��lo <br /> If yes,a special 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/APPLICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes fhat were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: 'S�,�,,� }C;�� <br /> Phone (day): b1� 6Crf7 �,9 b 3 <br /> Address: ��SS Hw�a- ��. �'�z-+r� City: ��.�,,,��y ZIP: SS�S,� <br /> Email and/or Fax: ,,, � - c r�.�,��. � �,�,,,� <br /> PROJECT INFORMATION: Overall project description: <br /> �- (�t�`f(6Y1 ��! <br /> Type of Project: Any earth movement may also require <br /> ( ) �model Fire Damage MCWD review&permits: <br /> ❑ Door s <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) $ i!?d <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 i annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the' orma , the a lication ma not be issued. <br /> Applicant's Signature: Date: �—��' f S <br /> Owner's Signature: Date: .S —1S — L� <br /> Last Updated:January 2015 <br />