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. <br /> , , City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel - Residential ONLY <br /> (i.e, wi�dows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �-- <br /> �O� Mailing Address: Permit number: ��l�n" � <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: �� / <br /> `p Street Address: Received by: <br /> yF � � _1��` 2750 Kelley Parkway Plan review fee: �f �,� <br /> t L `�� Orono, MN 55356 <br /> Akf S H��''� <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: <br /> Job Site Address: ��/O —/02 �/�—/( ��/o�/ �o �vG�iicc e o-�G <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Dispfay H e? ❑ Yes o <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 sufficieni on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: _ <br /> Name: .,aD�tvi+-�� ClPo.n�w � -T��c�. o� <br /> State License# 8C0 Q �o$� Expiration Date: ,� ,3/ �G � � <br /> Lead Certification Number: �y�T a/ ��a—a Expiration Date: ,��a�/ aU a0 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �6,� �d,3� ._�j� (office) �v�3 —5y�/—g i 6/ <br /> Mailing Address: al /07`' vt�cce �7`� City: / ,.y�o��"� ZIP: �`S'�.✓t�� <br /> Contact Person: ry�,�� G'�^,,4e���� Applicant is: ontra or / Homeowner (CircleOne) <br /> Email and/or Fax: /r��'c�C� -Fi�e�r�x,�r� . con., <br /> PROPERTY OWNER INFORMATION: <br /> Name: Cc��s.��sS '��g� <br /> Phone (day): 6��a-8'Fl?� — �/7�0 / <br /> Address: y�,� /��p� �Yav�o� S7' �'ets� City: �,/�yz�;yQ ZIP: SS��i/ <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: � � ,v ���l /�' i�^ � Scd �- <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt �epair ❑ 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.or <br /> Estimated Construction Valuation of Project(excluding land) $ S, yy9 <br /> . <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 information, a lic ion ma not be issued. <br /> ApplicanYs Signature: %'�� Date: /9 �6 <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 ��` ///�� n u�`� <br /> .r y--. <br /> v �7� <br />