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, . City of Orono <br /> Building 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: Q� / —d /� <br /> O PO Box 66 <br /> ,�� Crystal Bay, MN 55323-0066 � Date received: �Z�� <br /> q�o �.��Sfreet Address: q Received by: <br /> y � � 2750 Kelley Parkway �1� Plan review fee: , <br /> �tqkFSHo G ,� Orono, MN 55356 (' D/D <br /> �� <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: / l <br /> •Job Site Address: ��` % � ! ���'v �.�-� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> /f yes, a special event permit is required with Po/ice Department and City Counci/approva/60 days prior to the event. Shuttle bus servi e wi//be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORA/IATION: 1 <br /> Name: �Av i D rZqS (<d� �� � �.,��<�� G��ivS�.ecy�7l en� �. L- �, <br /> State License# 3� � � Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were consfructed rior to 1978 C� <br /> Phone: (cell) , j�-- �f (�j� "6d (office) � d,�-- `��5��,� /--� <br /> Mailing Address: � � ( c.� �,,�o(`y, � �r-� City:�� iy✓�C; ZIP: <br /> Contact Person: /� L'� Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: d b�c,S C� ,� �.�, � Gd ly� <br /> PROPERTY OWNER INFORMATION• � <br /> Name: ��Q rv 1,[.� �C��I�-y,, �� <br /> Phone (day): jr�-� �/� ��.Js�.� <br /> Address: l��,�j Gc���, �j p�,�� �,Q,M,(f�1Z, City:�/'L��'lJ C� ZIP��..�.�6 <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) ,�J Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www minnehahacreek.or <br /> Estimated Construction Valuation of Project(excluding land) $ j <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 t ' formation,the a li 'on ma not be issued. <br /> Applicant's Signature: Date: �y-L� ! ( � <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 ���� c ' 4� C.y / �K <br /> iC/(/ (, <br />