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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).7�I <br /> O Mailing Address: Permit number: ow/F( rj39` <br /> /.,W NO PO Box 66 <br /> / \ Crystal Bay, MN 55323-0066 Date received: 3 <br /> ( . Street Address: Received by: Y <br /> A y 1 <br /> 1:4• r 2750 Kelley Parkway Plan review fee: <br /> 'KEsr+oa�`� Orono, MN 55356 //, <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 419,�T <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 Bite Address: <br /> Will this be'a`Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes EtNo <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: DAU 1,0044 , <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) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (circle one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATIOlt <br /> Name: a V I u7 JC C-,A�1CV1 <br /> Phone (day): �j '�- Z Qq( ) <br /> Address: '30 Si rt.s RV1(-(n) L_^J City: t tQ 0/JO ZIP: S 5 35 <br /> Email and/or Fax: DTI) L. [N! C..c) ,n1 <br /> PROJECT INFORMATION: Overall project description: PAW i Y)O 61,\)i, {•c ()1A) 0111/2-- <br /> Type <br /> 4112Type of Project: Any earth movement may also require <br /> ❑Door(s) 12 Remodel ElFire Damage MCWD review&permits: <br /> • ❑Re-roof,asphalt ❑Repair El 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) ElSiding ElOther: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Estimated Construction Valuation of Project(excluding land) $ (',CC. 04 <br /> APFIJCANT RCKNQYYI_EDGg7IENT: <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 fo annually update our records and records of other governmental agencies required Py law. If <br /> you refuse to supply the information,the .••ication ma not be issued. <br /> Applicant's Signature: 4_1/r / ��" l Date: <br /> Owner's Signature: Apr- �1� Date: 3 /' 2-0 <br /> s <br /> Last Updated:January 2016 <br />