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� � City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel - Residentiat ONLY <br /> (i.e. windows, door�, siding, re-roof, etc. — NO STRUCTURAL EXPANSIOIV) <br /> O MailingAddress: Permitnumber: JC-'�lr —C t�;1._�<; <br /> PO Box 66 <br /> � � Crystal Bay,MN 55323-0066 Date received: ��� �'- f � �� <br /> Street Address: Received by: ��� �� <br /> y� ��C' 2750 Keiley Parkway Plan review fee: ` C'����< <{ ��ti�c � <br /> t�kESHO��G Orono,MN 55356 � _ <br /> Total Fee: / / J/ ;�/ <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �t /�!'� <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: ` ' ' � ' <br /> Job Site Address: �7 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,a specia/event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficieni on-site parking is availab/e. Non-permitted events will not be al/owed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �7l�Ut�� �`AIMrS Ct��>j'�i't:.T?-�i�� <br /> State License# ����C.��,� Expiration Date: 'y�1q� �r"}. <br /> Lead Certification Number: �; �� Expiration Date: �`t'4,... <br /> (for work on homes that were consfructed prior to 1978 <br /> Phone: (cell) �S Z-�„��--Z,-�,"� (o�ce) <br /> Mailing Address: � i�X� 51��� ,�µ � �-�� .- ;� � City:g�{� ��.�� ZIP:� ��`�c� <br /> Contact Person: -T���y Applicant is: Contract r�/ Homeowner (Circle One) <br /> Email and/or Fax: ��E�`f c�,� (.�C7K>t��i -- ;y-iq.µ,«-�S. G�,'k <br /> PROPERTY OWNER INFORMATION: <br /> Name: _�'�jHt� � ti7�"�S�.�c�a 4�1' ?Nr2��J <br /> Phone(day): <br /> Address: ��"J���-��� ��, City: p �� ZIP:�. <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: ��,i��~f O�c'�t ,y+� ��1�r— S`��`tt, �-�'t� f�a�, <br /> Type of Project: Any earth movement may also require <br /> ❑Door(s) ,�(Remodel ❑ Fire Damage MCWD review 8�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(spec(fy) ❑Siding ❑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) $_'�_�.s�� �-- <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 govemmental agencies required by law. If <br /> ou refuse to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: t '� Date: ���/-'��/�� <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />