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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> — A`', Mailing Address: Permit number: 076!8'�&d0`j' <br /> *''('? <br /> \ PO Box 66 <br /> Crystal Bay, MN 55323- Cet � Date received: /—A3—�g <br /> a Street Address: Received by: G�(�' <br /> --'S. 2750 Kelley Parkway JAN c' 9 2018 Plan review fee: <br /> Orono, MN 55356kESH�� <br /> �r'���yyn r� Total Fee: /�., I' 58---- <br /> Main: 952-249-4600 Fax: 952-249-4616 SOY' rNNO '6`(�;!b <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 INFORMATION: <br /> Job Site Address: 1955 Heritage Drive _ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes SiNo <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 I APPLICANT INFORMATION: <br /> Name: Thomas W. Wilson <br /> State License# n/a Expiration Date: <br /> Lead Certification Number: n/a Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) 952.334.8329 [Judy Anderson] (office) <br /> Mailing Address: 1955 Heritage Drive City: Orono ZIP: 55391 <br /> Contact Person: Judy Anderson [designer] _ Applicant is: Contractor / Homeowner (circle one) <br /> Email and/or Fax: _ice y- <br /> C <br /> PROPERTY OWNER INFORMATION: <br /> Name: Thomas Wilson <br /> Phone(day): 619_701.9783 <br /> Address: 1955 Heritage Drive City: Orono ZIP: 55391 <br /> Email and/or Fax: thomaswilliamwilson@gmail.com <br /> PROJECT INFORMATION: Overall project description: Adding (1) 2'9"x6'8" closet in existing,hallway/bathroom <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) Remodel ❑ Fire Damage <br /> MCWD review&permits: <br /> ❑ Re-roof,asphalt 0 Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof, cedar 0 Restoration 0 Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) 0 Siding 0 Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ' 0 Window(s) www.minnehahacreek orq <br /> Estimated Construction Valuation of Project(excluding land) $ 775.00 <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•.1 b- information,the a..lication ma not be issued. , <br /> Applicant's Signa re: , Date: ,,�i!�!/ :7 <br /> Owner's Signature: I Date: / rl' a <br /> Last Updated:January 2016 <br />