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. City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O�O Mailing Address: Permit number: � ; ^� • �` .- <br /> PO Box66 ��� � <br /> Crystal Bay, MN 55323-0066 Date received: � —'�`�—d --. <br /> StreetAddress: _Received by: ��'� <br /> � t,� ��,�� Orono, MN 55356 � .an review fee: C(�-(.�_�� r„z �� � t� <br /> ti�, � 2750 Kelle Parkwa . ,� � <br /> 'CESH� <br /> Total Fee: / � . n ; <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. K. <br /> Incomplete applications will be returned. (Please print) �``{`�' ` ' '" � ° <br /> �' , <br /> GENERAL INFORMATION; „ I r. <br /> Job Site Address: �� r'� , Sl,��� `' ,' ! , <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other isplay Home? ❑ Yes No <br /> ff yes,a special event permit is required with Po/ice Department and City Council approval 60 days prior to the event. Shuttle bus rvi wil/be <br /> required unless applicant demonstrates s�cient on-site parking is available. Non permitted events wil/not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: , C ,� �.-c<"�- � ,�, � �, <br /> State License# - j Expiration Date: �+ �p <br /> Lead Certification Number: ��Cy�� - 5� 2c,� _. ( Expiration Date: �, �Zz � Z�� l� <br /> (for work on homes that were construcfed prior to 1978 <br /> Phone: (cell) �j�. _ ���� (office) <br /> Mailing Address: � ,�p �' ' � •�� �(�c City: a-t Lo,��s b'�v k- ZIP: �; fl� <br /> Contact Person: � r',ti� ��r s r�sc�„ Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: _C:�t'-�.�,�•� 5�ti {�orti _ <br /> Phone (day): � �� , <br /> Address: �iL�"7 rJ�r't�S L�o r-�_ �r , ,;�.. City: ��� c;�:� r ZIP: <br /> Email and/or Fax: . <br /> PROJECT INFORMATION: Overall project description: t� :��� <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&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) ����M-T-��- '�'n.�'��n www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 4 �U� <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 /> so�ely 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 ' ormation tha a lication ma not be issued. <br /> ApplicanYs Signature: j` � �_� Date: ' '� '�`'��' <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 ��r/�(/( �� �� / cL� <br />