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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 /> A, Mailing Address: 97 <br /> �Oi VO PO Box 66 Permit number: 010/7-0// <br /> ] 1 Crystal Bay, MN 55 3-0066 Date received: 9- J 8/7 <br /> i" Street Address: / /�," q Received by: <br /> ti� L� 2750 Kelley Parkw y / /✓ /' / Plan review fee: �[//rt7// y� <br /> `AkESHOv-� Orono, MN 55356 <br /> Total Fee: tfp 7,11. V5-_,‘L <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: 4C 10 (1) . �ti(, L-41-- b <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 bu rvice 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: - --rj j- .L +4M ---- <br /> State License# -fit S 0°1 -^ Expiration Date: __ 12 rel' <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell 6 92)C? - S(1 �' (office) C012_- SSS-c -7(._49 <br /> Mailing Address: 42 b\ Sly(vS ET City: -I c,WLIP: `SSS g L/ <br /> Contact Person: , <br /> �-� Applicant is: t\Contractor Homeowner (Circle One) <br /> Email and/or Fax: GICr -}-0 -r-T� — -f--CM L27 . C <br /> PROPERTY OWNER I FORMATION: , <br /> Name: :/ <br /> C �] Pi � <br /> Phone(day): <br /> Address: 4 0 cni \Q1l/1- (.4 --;'r- t) City: (4%_OM) ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) emodel 0 Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> 0 Re-roof,asphalt ❑ Repair ❑Storm Damage <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) $ L ni (_ D')- - <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 ca .. be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to a al u.,. - .ur -cords and records of other governmental agencies required by law. If <br /> you refuse to supply the in ormation, e app ion :y not ,- •- ued. <br /> Applicant's Signature: 1 Date: etard. <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />