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City of Orono <br /> � Bui�ding 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: �� "`vU ,y <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: / <br /> a � <br /> Sfreet Address: Received by: <br /> ti�, G� 2750 Kelley Parkway Plan review fee: <br /> t �, Orono, MN 55356 <br /> qKESHOtt <br /> Total Fee: /S 7 � <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. (P/ease print) <br /> GENERAL INFORMATION• <br /> Job Site Address: F ']��<.,, r, � ��} - - ;/ <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/AP LICANT INFORMATION: <br /> N a m e: '�'"� _�F�ZT�,C� ;,.s.1--1�� C,�, �-.l_�. <br /> State License# Q L �S C' 7�:f Expiration Date: � <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (�`a- �7� -�� � � � (office) ,��,-,� <br /> Mailing Address: (o�j y G 12o F a��r" �.�E � City:(�����L� ZIP:J 5�?5 D <br /> Contact Person: � ^ A licant is�ontractor / Homeowner <br /> ���.1- �A� 1� f�,5���L..E;�S PP (Circle One) <br /> Email and/or Fax: r�,1(Y'1 t� 1Zc`k� F:i:vi�,�% �t:•l_ . (-c�,r�..) " <br /> PROPERTY OWNER INFORMATION: <br /> Name: '�����_� /��c.�,-� <br /> Phone(day): (o��..�.�,,crj�� <br /> Address: ��» Qja�,� � ,°��:c �- City: �r.�..:� �. ZIP: ,j - 3 r7� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall pro�ect description: � -� _ ��' <br /> Type of Project: Any earth movement may also require <br /> Door s ❑ Remodel MCWD review&permits: <br /> ( ) ❑ Fire Damage <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) $ <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 the inforrnation,the a lication ma not be issued. <br /> �- � <br /> ApplicanYs Sign re: Date: do ' <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />