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�y� <br /> �C:'l�' �:7 <br /> ' 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 /> �ci O Mailing Address: ��� �?� <br /> r��' PO Box 66 Permit number: <br /> r �� Crystal Bay, MN 55323-0066 Date received: �'�J�— <br /> 1 Received by: <br /> 1 Street Address: <br /> y�, G� � � 2750 Kelley Parkway Plan review fee: ��/�`� <br /> !�'�fSHO�� � Orono, MN 55356 ,�p�9��sfj <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: �j f �/ , /�j�� l �� <br /> Job Site Address: �t� ,� ��� G e <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. Shutt/e bus rvice wi/l 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: /�l��C�/�����1'�?�.�/� �U/L�/�CC CJ � `'c��J�� Cl�(C� �c�o <br /> State License# �� Expiration Date: �-i,�'— !� <br /> Lead Certification Number: �/�7�; L�l� � . Expiration Date: � - ,�1 1 � <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �/a - (�� - d(� �� (office) v�.—�j33 — G a73 <br /> Mailing Address: Q ,v,,/ T��//�,¢ � `�j . City: �/ �� ZIP: <br /> Contact Person: ���jC p�� ,�,�� Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: �62C� (c� ��J�� Gij�jC/G� .�,t� <br /> PROPERTY OWNER INFORMATION: '/ <br /> Name: ��1�.. 1�iQJ.�U1� <br /> Phone (day): • ::� � •-- �?-- � � <br /> Address: � L/�/j���,/ /,�Y�. City: a�L��� ZIP: �J �c�� <br /> Email and/or Fax: �� �t, ��,�_ �� ���,y1 <br /> . o <br /> PROJECT INFORMATION: Overall pro ect description: ��C� �•�• ��QM• £ �A-1/� �RD/ti( �,�/r1• �M• <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 a ually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I e infor tion, e a lication ma not be issued. <br /> Applicant's Signature: `�`—-" Date: .3 - Z 3 - �� <br /> Owner's Signature: ��� Date: <br /> I ac4 1 Inrl�4cr1� lan�mni 7(11R v <br />