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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: o?0/4 -0` ` b <br /> POBox66 <br /> �I, Crystal Bay, MN 55323-0066 Date received: /'-3 StreAddress: 1� �� C i� 0Parkes �' Planrevwfee: '17✓. 5.,,,,, -- Orono, MN 55356 d /6, .,/7 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 .ci.orono.mn.us <br /> This application form must be completed in full and all required information must b_a submitted. <br /> Incomplete applications will be returned. (Please print) ' <br /> GENERAL INFORMATION: <br /> Job Site Address: /5 3 (�o rc c t mac.eJ pia t-c_ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes o <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 INF RMATION: <br /> Name: X L e <br /> State License# 3c3 Li Expiration Date: 1NGL No( ,/ z a (S' <br /> Lead Certification Number: iel-T_ // 7y.0 —/ Expiration Date: 3-4.4ve- ,2 /4-- <br /> (for <br /> L(for work on homes that were constructed prior to 1978 <br /> Phone: (cell) /) 36,.& ?a / p (office)9 ?,53--, ? <br /> Mailing Address: 17i, J3o-f. Y t Cii y . ,K ZIP;;,---9-3 -r— <br /> Contact Person: evi it 1`t'9 �t... Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: 41..c._ 9._,./.., 2x 1 (� Vic,/ „&'f 41 <br /> PROPERTY OWNER INFORMATION: <br /> Name: 5 e-c,,,•_ \/1,(e-- l�e-v-,tiwlr 1- <br /> Phone(day): 11.-- 33 . 7q 3'1 <br /> Address: /53v 4rL.e..,—� y es, INtee--L. City:prc ZIP: <br /> Email and/or Fax: <br /> ,;(4,,A,- i(. !✓ ` C . T) <br /> PROJECT INFORMATION: Overall project description: r ii-A&J.l• Le--,S--u- . ;vti 1 IA r+-.G i,e-r <br /> Type of Project: Any earth movement may also require <br /> MCWD review&permits: <br /> ❑ Door(s) Remodel ❑ Fire Damage <br /> ❑ Re-roof,asphalt 0 Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ 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 /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 5p?/ o-7:70 "— <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 suppl r`information,t ap lication may not be issued. <br /> Applicant's Signatur :' _� Datea/ /Z <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />