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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 /> A, Mailing Address: I Permit number: <br /> �QWec.> <br /> PO Box 66 (� �I ���7-0/ `� <br /> Crystal Bay, MN 55323-0066 , I ,tom Ci Date received: / I - ?7-1 7 <br /> Street Address: ppp"`///"`/// Received by: 4-6-- <br /> y4 2750 KelleyParkway <br /> p/�'-� Plan review fee: (V �6 <br /> Orono, MN55356 t( Al(/ �ytESHO° -A0I7--015.4 <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 INFO <br /> dress: TIONI y 1 F lin uoucl !-\Vt 1 /1� F'L lU 55-3L <br /> Job Site Address: .-1 �� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or otherDilsplay Home? ❑ Yes Z No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORM TION: r <br /> Name: {-�(�MEUtJYI['.Y• seg i►, TGifYhtn��►1 gelOid <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) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER,.(NFORMATI <br /> Name: K (J1 111P S <br /> Phone (day): all- c2- , Ql . <br /> Address: !_ u . G e ~' ^� City: oro I� ZIP: cc-W-1 <br /> qui)Email and/or Fax: qui) A hes& fI yG pG- it irk 1/ <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> IDDoor(s) IDRemodel 0 Fire Damage MCWD review& permits: <br /> 11 Re-roof, asphalt ❑ Repair CI Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re roof, cedar <br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof, other(specify) ❑ Siding Other: (specfy) Phone: 952-471-0590 <br /> ( Fax: 952-471-0682 <br /> ❑Window(s) 1101 SV) NA5O tnf www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project (excluding land) $ 1 c, CO(! <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 /> you refuse to supply the information,the application may not be issued. <br /> Applicant's Signature: / Com/ Date: <br /> Owner's Signature: tr-------°L- Date: I I l 0-7 <br /> Last Updated:January 2016 <br />