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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 /> �0 Mailing Address: Permit number: 026)ET—o-0 (O <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: /3�-'7 <br /> y ` 2750 Kelley Parkway plan review fee: <br /> �e ktsxo� G Orono, MN 55356 43 (o <br /> k CD <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 71 <br /> This application form must be completed in full and all required inf tion rr _ st be su fitted. <br /> Incomplete applications will be returned. ( lease print <br /> GENERAL INFORMATION: Z-1-KC-F,CO �� <br /> Job Site Address: 4(p�� /ls / S�biQ-� ���`r✓ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes ;,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 INFORMATION: / <br /> Name: tu&&4A) 80A) <br /> State License# jtr '3 j(Qp739 Expiration Date: <br /> Lead Certification Number: NA-1-' �7ZIo �-1 Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) ( Z,7()2-- g (office) 7(,, 3 — 2_ff _ c�7c/v <br /> Mailing Address: L City: ply ZIP: <br /> Contact Person: 0,t-A y7oA) �-)4J 66,4j Applicant is: onrac 5:r>/ Homeowner (Circle One) <br /> Email and/or Fax: , t461an Cp j-6+f.(f;V 1) CoMC a-4+ , nem <br /> PROPERTY OWNER INFORMATION: <br /> Name: CkmEfl-OU + AA 0LL,V 'POf-"TE/L <br /> Phone(day): 12 -(off /y&7 (Cqffi CaOAJ <br /> Address: ++�4 �y , ,s-tof-F, JV_XQE City: 6(2-0A)® ZIP: <br /> Email and/or Fax: /� �y �l fr(2,) JA!Q?e , cpM <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: 14 ) Any earth movement may also require <br /> ❑ Door(s) Z4 Remodel El Fire Damage <br /> 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) www.minnehahacreek.org <br /> Estimated Construction Valuation of Project(excluding land) $ 060 <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 ipfpr05_abpn,the applicaWn may not be issued. <br /> Applicant's Signature: Date: 1 <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />