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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 /> W <br /> o Mailing Address: Permit number: 201 T-oo/1p 5— <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> //r6 <br /> 2750 Kelley Parkway Plan review fee: <br /> Orono, MN 55356 /,'_O/H( <br /> Kf:stio <br /> Total Fee: r2t f 3 <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 /> Job Site Address: S.-{o ,co 1SLA(J GEL-AC) tv <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: SCS k Ar\-. <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) Cc\ \C-0 1..kocca �jcr y (office) C 2 ) ZZ3 ( t CU <br /> Mailing Address: '2(6 PcS 27 City: 1.c.,2 ZIP: m 33 I <br /> Contact Person: � wL SC\*M �� Applicant is: Contractor / omeowne� (Circle One) <br /> Email and/or Fax: w s c_\r-,,pr\ r- 6, \� cu'v, <br /> PROPERTY OWNER INFORMATION: <br /> Name: � � 4wti w�5c������ <br /> Phone(day): Cc-c\ct <br /> Address: Z q—‘ w f�Si+�A ; 2g City:E,s6 ZIP: v <br /> Email and/or Fax: CVVV\�� er ci <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) rgrRemodel 0 Fire Damage 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 <br /> 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) $ I o <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: Date: 2- ( \'c ( a <br /> Owner's Signature: ��`' Date: Z( t I ( <br /> Last Updated:January 2016 <br />