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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�T Mailing Address: Permit number: `�U/��' <br /> � �VO PO Box 66 � <br /> Crystal Bay, MN 55323-0066 Date received: � <br /> � <br /> Street Address: Received by: J <br /> 9�, G� 2750 Kelley Parkway Plan review fee: � a� <SCF/�f�'� <br /> t Orono, MN 55356 <br /> �kESHO�� , <br /> Total Fee: j,��,J �� <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) L�Y�1� ��-'�"�S <br /> GENERAL INFORMATION: , - � ,� � <br /> Job Site Address: �`��r:s'T��� �U��'f��� ��i�_���_ ��, �� v�',_ ����� �-'�"�c� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �J No <br /> If yes, a specia/event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/AP�.�ICANT INFORMATION: <br /> Name: /�,,�y- ,C/-��-�;��.;: �.:,���% ..� hcy <br /> State License# x'c����,i �'''� Expiration Date: � ?j c���, <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �';��_ rz�, i �- -���. � (office) �i-5�� —�-:�-=f �i�-i� <br /> Mailing Address: ��'.<;�`s�`� �<< �,�� ;�(�� City:���.c �-_,�;,,�� ZIP: ,S'=:5'� 4/ <br /> Contact Person: �Qrf y _ / �;� Applicant is: tractor� / Homeowner (Clrcle One) <br /> Email and/or Fax: �,�;y�_j.��,���,w,� G , <br /> �,q �GC!�^ � ���'I <br /> PROPERTY OWNER INFORMATION: <br /> Name: C Lt��l�� %,�,.� <br /> Phone (day): ��'2 E�S'_'Z��c� <br /> Address: .�� ���,--{-� 5��;��_ � �..�._ City: �r�`,-ti� ZIP: <br /> Email andlor Fax: <br /> / < 1 <br /> PROJECT INFORMATION: Overall pro'ect description: ��/` ! '� C`� G�'l � , CC���-`I- <br /> Type of Project: Any earth movement may also require �'� <br /> ❑ Door(s) �Remodel MCWD review 8�permits: <br /> ❑ Fire Damage �;�.,�.-_ � <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,cedar 15320 Minnetonka Blvd <br /> ❑ 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.orq <br /> Estimated Construction Valuation of Project(excluding land) $ /5���=� "— <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, he a lication ma not be issued. <br /> Applicant's Signature: �l��� "���f.�'�g Date: /�G� � � �`''�� <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />