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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 S7RUCTURAL EXPANSION} <br /> �0�� Mailing Address: Permit number: [�( — <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: l'� L �'"'�� <br /> Street Address: Received by: <br /> y�, � 2750 Kelley Parkway Plan review fee:� ��,,' ' <br /> � �' Orono, MN 55356 � <br /> �K�SHOR�` 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 p int) ������ /11��i� <br /> GENERAL INFORMATION: <br /> Job Site Address: 3 2�� �� e �� � . � Z��C� M �.S 3�� <br /> Will this be a Parade of Homes, Remodele s S owcase Home other Display H me? ❑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 s rvice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> /APPLICANT INFORMATION: <br /> Name: ��U�,y��' l�L� �/2 �_ /� <br /> Expiration Date: <br /> L� . Expiration Date: <br /> (for work on homes that were constructed prior to 197 <br /> Phone: (cell) (D { Z � 5 - 2 5 (office) ��Z - 3 �,3 - �z �� <br /> Mailing Address: L.a �� � � �� e�- City: ;;t)�'^ Z l� ZIP: � j <br /> Contact Person: Applicant is: C-ontrae#or / Homeowner (Circle One) <br /> Email and/or Fax: S� �j W : <br /> PROPERTY OWNER INFORMATION: l <br /> Name: �A t> ( :� G (�y� � �1 dZ_ <br /> Phone(day): �o(2, -��5 - l 2$ (P <br /> Address: �,� yt.�� City: ZIP: <br /> Email and/or Fax: ' (�J.,a,;_{ �3�3��r'y�Cu�C� <br /> PROJECT INFORMATION: Overall project description: i �G� (��.. �-�'�-�v �}'�'� <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) $ O Q� <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 /> confdential. 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 u I t e infor the lic tion ma not be i ed. <br /> ApplicanYs Signatu�: � ' n` Date: �� C�-� �� j� <br /> v <br /> Owner's Signature: Date: � �- ( [� ` ��1 � <br /> � <br /> Last Updated:January 201 <br />