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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 /> �O�O Mailing Address: Permit number: G�� 7 "D(,��i <br /> PO Box 66 <br /> � Crystal Bay, MN 55323-0066 Date received: ��1 S�/ � <br /> i <br /> StreefAddress: Received by: �� <br /> 5�, � 2750 Kelley Parkway Plan review fee: /"l <br /> t � Orono, MN 55356 <br /> �k£s���� _7� s� <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: l / <br /> Job Site Address: � � � "" O �7'L� ��G' zt�� 7 <br /> Will this be a Parade o omes, Remodelers Showcase Home o other Display Home. ❑ Yes ❑ No <br /> If yes,a special event permit is required with Police Department and City Coun il approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-srte parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> � <br /> Name: 1�1I11. �K' ���� �� L-YX..�_ , <br /> State License# � l Ex iration Date: � <br /> ,,������ 7� p� /t <br /> Lead Certification Number:,��T�c, ��_� Expiration Date: 5-.�U <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) �. � .1/��'�D� <br /> Mailing Address: ���np�, „���� %,��.� City�SS�� ZIP: ��,�� <br /> Contact Person: �1�,��� ��,,y-�E,�--� Applicant is: c__n rac o?�Homeowner �c���ie'Gne) <br /> Email and/or Fax: jL'G'2r'/So72� InrJ�v��c�*.� 7��• fz'S.�� c�'�.�0 <br /> PROPERTY OWNE INFORMATION: <br /> Name: }�c�-s`�;c� /»t �C u S� `�C <br /> Phone (day): <br /> Address: ��� L/� �Sf'� _ «�c; (C" City��1��� •�w f�z ZIP: S S.�'�� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project descriptio � � (,,Ce �C`� �.��n c�,r )c'.�s� G �-�< ' <br /> Type of Project: Any earth ovement may also r re <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> �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) iding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orp <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 informatQn, the a lication ma not be issued. <br /> Applicant's Signatur . y-° . -r�./�7�I Date: S ���� �,� <br /> v/ <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br /> J /l • � <br />