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City of Orono <br /> ing Permit Application for Maintenance / Replacement/ Remodel — Residentiai ONLY <br /> �4.c�. Wttif�t9'��L;�, �C:':sl'S, i1�I�1� ,b. ;:��:3jy ���, •�. �s�;� 3�����,; , <br /> 1 <br /> �O A,O Mailing Address: �?b`!� —D/ <br /> 1 V PO Box 66 Permit number: <br /> Crystal Bay, MN 55323-0066 Date received: /l��vZ —/ �, <br /> � ,, _ �� Street Address: Received by: �' <br /> �'F G� - ���' 2750 Kelley Parkway Plan review fe : <br /> lqk�SHO�� Orono, MN 55356 <br /> Main: 952-249-4600 Fax: 952-249-4616 www,ci.orono.mn.us Totai Fee: � �9� ��] <br /> � <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ,�j � S ��E 't��t V E <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> /f yes,a specia!event permit is required with Police Department and Cify Counci/approva/60 days prior to the evenf. Shutt/e bus service wi//be <br /> required unless applicant demonstrates s�cient on�ite parking is available. Non-pemtitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �1�C.1+RC.l JOivE� <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (pla -'� I� -d41y (office) <br /> Mailing Address: _ � • � � �� City: �,�� Z,�T,� ZIP: �S3q <br /> Contact Person: Applicant is: Contractor / Homeowner <br /> Email and/or Fax: � � (c���ie o�e� <br /> _�k� �c; �otvE S'�1 lA S <br /> PROPERTY OWNER INFORMATION: <br /> Name: .l�'��C <br /> Phone (day): <br /> Address: — City, Z�P_ <br /> Emai�and/or Fax: <br /> PROJECT INFORMATION: Overall project description: 1-1�(�IV�� � St�C jjl��.mEti� da � t�L;�ma�N <br /> Type of Project: <br /> Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review 8 permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,cedar ❑ Restoration 15320 Minnetonka B{vd <br /> ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) ❑Siding ❑ Other:(specify) Phone: 952-471-0590 <br /> ❑Window(s) Fax: 952-471-0682 <br /> www.minnehahacreek ora <br /> Estimated Construction Valuation of Project(excluding landj $ r"J� ; p p <br /> APPLtCANT 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 altemative but to <br /> reject it until it is complete; <br /> • Some or all of the information that you are asked ta provide on ihis 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 annuafly update our records and records of other govemmental agencies required by law. If <br /> ou refuse to su I the information,the a lication ma not be issued. <br /> Applicant's Signature: -�=_� � r-- Date: ��/d /i'�( (� <br /> Owner's Signature: � Date: �1 a�� �4�(� <br /> Last Updated:January 2016 —��'� <br /> �;�'► ������/(� <br />