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� • Gity of Orono <br /> Building Permit Application for Maintenance ! Replacement / Remodel <br /> (�.�e. �n►i�cl�►ws, doors, siding, r��-r�c�f, et+�. — NO �TRUCT6JRAl. EXPAIUSIC)�iy <br /> �O�r Mailing Address: Permit number: ���0'"��Q <br /> 1 YO PO Box 66 — <br /> Crystal Bay, MN 55323-0066 Date received: /— —J <br /> � � Street Address: C1,'' ��1•I y Received by: 'e— <br /> ��F � 275�Kelley Parkway P(an review fee: <br /> \�q �,L Orono, MN 55356 /�,�� <br /> k�S Ft 04 <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 appiecations wil! be retumed. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �- rw� ✓� , <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> If yes,a speciaJ event perrnit is reguired with Po/ice Depa�tment and City Council approva160 days prior to the everrt. Shuttle bus service wil/be <br /> required unless applicant demonstrates sufifcienf on-site parking is available. Nort-permitted events will nof be allowed. <br /> CONTRACTOR/APP I ANT INFO M Tf0 ; <br /> Name: �l( �A�A��rC �,.y-� <br /> State License# �C �[�� c�S1 Expiration Date: <br /> Lead Certification Nu-�m ler: Expiration Date: <br /> (for work on homes that were constructed prior to 9978 <br /> Phone: (cell) �1'L ,3�L (�'�/ (office) <br /> Maifing Address: '� ! � City: �n �I��j�! ZIP: �„�E/ <br /> Contact Person: �,�, ,�,�,.,� Applicant is actor / Homeowner (CircleOne) <br /> Email and/or Fax: J��,t,�,�,,,,�����(��, <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATt�N: C?verall ro'ect description: <br /> Type o#Project� Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage N�CWD review S permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven,MN 55391 <br /> ❑ Re-roof,other{specify) ❑ Siding [$Ot er. (specify) Phone: 952-471-0590 <br /> ���. , i�_�' � Fax: 952-471-0682 <br /> [$J Window(s}�� � ��� L�I www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ / C�R3 <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 /> solety 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 camplete; <br /> � • Some ar 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 gen Ily cannot be given to tt�e public but can be given ta the subject of the data. <br /> � Gonfidential data is information which g erally nnot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this infonnatio is nually date our records and records of othe�govemmental agencies required by lawr. If <br /> ou refuse to su f t info af e a catian ma not be issued. <br /> ApplicanYs Signafure: Date: �� 'r <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />