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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 /> Mailing Address: Permit number: p261/ -Q(' <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> tiF ✓� 2750 Kelley Parkway Plan review fee: c&LU4 <br /> l ykFSHO Orono, MN 55356 <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 INFORMATION: <br /> Job Site Address: 2-535 OLS 6e;Ar+{ 2t�RD i.�au 2�t,� rnu SS��I <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: '3AWt'02SE nE it�NFa2S �UtiLpEi2S <br /> State License# (�,� 002382- Expiration Date: <br /> Lead Certification Number: NRT-Zlia(.-t -2 Expiration Date: S/ 3/ <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) &1 2--315 - 339"] (office) -7(0?, -9` 3.- Z)352 <br /> Mailing Address: 4-140_42"o prt,E N City: (2ZAairASDfitE ZIP: SS422 <br /> Contact Person: JE2loir j" l!✓rr►i_L7 Applicant is: on rac o / Homeowner (Circle One) <br /> Email and/or Fax: r�2�Sa.ccm _(a3-533- S-7t/o <br /> PROPERTY OWNER INFORMATION: <br /> Name: Txn t JF�LAC-1 A Cmo01_E <br /> Phone (day): q 5 2-A-71- <br /> Address: <br /> 7l-Address: 2535 ULb (->cR Qbpro City: U�2_P6":4 ZIP: <br /> Email and/or Fax: Cod;4&)0Me_c.ma;l .com <br /> PROJECT INFORMATION: Overall project description: WE5Ct 2�mnaE�- <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) <br /> Remodel ❑ Fire Damage 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: 952471-0682 <br /> ®Window(s) www.minnehahacreek.org <br /> Estimated Construction Valuation of Project(excluding land) $ <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: 1� ZUl6 <br /> r <br /> Owner's Signature: Date: <br /> Last Updated:January 201 <br />