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City of Orono <br /> Buildir�g Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> O Mailing Address: Permit number: �� <br /> �- �O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: � � <br /> � � Street Address: <br /> Received by: � <br /> y G� 2750 Kelley Parkway Plan review fee: 6��-Ci ( <br /> `� �, Orono, MN 55356 U� <br /> ��'CES H 0� �C�:. <br /> Total Fee: �✓ <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us (�� �L� <br /> This application form must be completed in full and all required information must be submitted. ,�.� <br /> Incomplete applications will be returned. (P/ease print) �`�' ����� <br /> GENERAL INFORMATION: 7 '>%, <br /> Job Site Address: �SO � Ll��=.CVi�� � ��z. 2�NO ��� J�35 � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other D�isplay Home? Yes o <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/APP ICANT INFORMATION: <br /> Name: �� j,,j� <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were construcfed 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 OWNE INFORMATION: <br /> Name: - ^�NS �i`�. RRc� <br /> Phone (day): (o�Z '� '�.� l 3� <br /> Address: � �p� L/1�,�V���� '"j�[2 City: ���(�0 ZIP: �/�.� <br /> Email and/or Fax: 0.l �flc•sOC ac r � � l , �„�. <br /> PROJECT INFORMATION: Overall project description: k-'��t��er� Z'��^� .�!��^ ��2�^a <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.ora <br /> Estimated Construction Valuation of Project(excluding land) $ D DO <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 inform tion which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this inform tion is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I e in rma ' n,the a lication ma not be issued. <br /> Applicant's Signature: Date: (,J � �`� <br /> Owner's Signature: Date: v � <br /> Last Updated:January 2016 ��� � (� l�� <br /> l <br />