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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 /> �O�O Mailing Address: Permit number: �l.s d�l l�D <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: O�� —� <br /> Street Address: 1 Received by: Q -D. <br /> y � 2750 Kelley Parkway ti�'�" � Plan review fe <br /> `� �,L Orono, MN 55356 � �I1� � ! <br /> `qkFSH�� - �� 7. �� <br /> Total Fee: <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: ��p /�G�ry T' �/�-�rY� �n , ��eo n/D . �YI rU �g S-.�.�-� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑�Yes ❑ No <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: /�,c��L J`�.�iR�v�CL� ��ielB"N/� <br /> State License# , �__�; ,�,; �� � Expiration Date: <br /> �.. <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner �c���ie o�e> <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �i c s�3E.L-- �aevt vt G,C.. �-- <br /> Phone (day): �jSo2-�io�-1 - �e y 6 <br /> Address: ��o /�,,,,r �-�.,�,-,-, f�.� aty: p�o n/fl ziP: 5,53.SG <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ 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(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) $ �' <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 o cords and records of other governmental agencies required by law. If <br /> ou refuse to su I e' formation, the a lication ma n be issued. <br /> ApplicanYs Signature: Date: a��/�/.5! <br /> Owner's Signature: Date: ��/ �/�.o �� <br /> Last Updated:January 2015 <br />