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• • • <br /> City of Orono <br /> Building Permit Application for Maintenance I Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> Mailing Address: Permit number <br /> PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received - - <br /> Street Address: Received by: <br /> 2750 Kelley ParkwayPlan review fee: <br /> 114SH041 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 /> S <br /> Job Site Address: Igo Orono 2rckara Rd - <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes JNo <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: .5 cher-R.4, to MS.L(,t yr b -4, Co . <br /> State License# Bc.023q 31p Expiration Date: 3 S3/ /to <br /> Lead Certification Number: Nici--1 a '3 05.a Expiration Date: S ? olpa p <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) q5.1- ?77 -/6.6s) <br /> Mailing Address: 1�5 £xce(stor Rivo( City: f�-d�kil s ZIP: .$53q'3 <br /> Contact Person: r (i,,f h Applicant is: Con{ractor / Homeowner (Circle One) <br /> Email and/or Fax: ca't flc rvso r.a SCk ere.r lr'o5 , <br /> PROPERTY OWNER INFORMA IO <br /> Name: 3-0e- <br /> Phone(day): - , - . . / <br /> Address: IgD Guava l'/cl ( / City: N1la-412A-4"-GL--ZlP: 5539/ <br /> Email and/or Fax: <br /> • <br /> PROJECT INFORMATION: Overall project description: izeplac' 4- VJ to.oko S 6h •^7(,9-10ir jr0 orvifcf' S. <br /> Type of Project: Any earth movement may also requir <br /> ❑Door(s) 0 Remodel 0 Fire Damage MCWD review&permits: <br /> ElRe-roof,asphalt 0 Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar El Restoration 0 Water Damage Deephaven,MN 55391 <br /> 0 Re-roof,other(specify) 0 Siding ❑Other:(specify) Phone: 952-471-0590 <br /> Fax: 952471-0682 <br /> 9 Window(s) w/ww.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ .67/ 7# tv0 <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 th information,the ap lication may not be issued. <br /> Applicant's Signature: ifowr ' Date: 41/0V-I1 b <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />