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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 /> �1 O Mailing Address: Permit number: � �����S <br /> PO Box 66 <br /> r � - Crystal Bay, MN 55323-0066 Date received: - �-� "�7 <br /> �' �\1 Street Address: , �� Received by: <br /> � ____ �� -__, <br /> y � .� 2750 Kelle Parkwa� � <br /> �. �. � � Y ��� �� Plan review fee:_ �� , �7 <br /> �, � Orono, MN 55356 � �`L� <br /> � ��.�" - _ <br /> �qk£s rt o Total Fee: ��1��fl� �0� _ <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: <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 un/ess applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ��r�R 21L���- �{- ��S <br /> State License# �� Expiration Date: � <br /> Lead Certification Number: N�T-1��15�j-2 Expiration Date: ���,Z �� �� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �' ' �� ' (office) �j�� �'���j� ��lU� <br /> Mailing Address: � City: - ZIP: , �3�: <br /> Contact Person: ��v;a, Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: � � ,��, ^ � <br /> . <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <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 <br /> MCWD review 8�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 our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the inf rma'on, he licat' n ma not be issued. <br /> Applicant's Signature: � � � � Date: Z,����� <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />