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City of Orono <br /> Building Permit Application for Maintenance ! Replacement 1 Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> Mailing Address: <br /> 0 PO Box 66 Permit number: <br /> Crystal Bay, MN 55323-0066 Date received: " <br /> h Street Address: Received by: <br /> s �, 2750 Kelley Parkway Plan review fee: <br /> Orono,MN 55356 <br /> �K�SftOQ� Total Fee: 7 <br /> + 1 <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 INFORMATION: <br /> .fob Site Address: 7 <br /> Will this be a parade of Homes, Remodelers Showcase Home or other Display Home? LJ Yes NNo <br /> tl yes,a special event permit is required with Police Department and Q1y Couricil approval 60 days prior to the event. Shuttle bus setWe will be <br /> raquin3d unlass applicant demonstrates sufficient on-siie parking is available. Non-permifted events will not be affowed <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: - '&— ' <br /> State License# .(ter 4 �2,Y 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: 0y City: ZIP: r ' <br /> Contact Person: Applicant . Con rac r Homeowner (circie one) <br /> Email and/or Fax: / <br /> PROPERTY OWNER INFORMATI N: <br /> Name: �y,s � l <br /> Phone(day): <br /> {address: � �y 9 " City: ZJP: <br /> Email and/or Fax: <br /> T INFORMATION: Overall reject description: <br /> PROJECT project <br /> Type of Project: y earth vement may also require <br /> MCWD review&permits: <br /> [:1Door(s) El Remodel C1 Fire Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> C]Re-roof,asphalt F1 Repair ❑Storm Damage 15320 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration Water Damage Minnetonka,MN 55345 <br /> ( � fy) Phone: 962-471-0690 <br /> ❑Re-roof,other(specify) ❑Siding ❑Other: (specify) Fax: 952-471-0662 <br /> Window(s) www,minnehahacreek.org <br /> Estimated Construction Valuation of Project(excluding land) $_ S2 Cyxf <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 govemmental agencies required by law. if <br /> you refuse to supply the information,theapliqation ma not be issued. <br /> Applicant's Signature� � Date: 3f <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />