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. City of Orono <br /> � Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> =.v, v�+inc�c�ws, dr����, s��i�c,�, ��-r�r�f, e�c;. � �� �T�l�G�T�1F�A� �X�Ai��lC�fi�� <br /> �O� Mailing Address: Permit number: � Z; - f"` , ��i I <br /> PO Box 66 <br /> � Crystal Bay, MN 55323-006 ��V Date received: ���-- — <br /> i <br /> Street Address: �� Received by: <br /> y� � 2750 Kelley Parkway Plan review fee: �l��c.c.�.d <br /> t `' Orono, MN 55356 � <br /> 9kesH���� �D! ��� <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. (P/ease,Print) <br /> Job SiRe Add eORMATION: ���) � Y C � / ,�,� �t' - � / N��� �r /�l� ,° ,��-Z�7`�� <br /> 1 c�t,y l l, L,r, vr � �� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Dis ay Home? ❑ Yes No <br /> If yes,a special event permit is required with Police Department and City Council approval 6 days prior to the event. Shuttle bus se ic will be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPL,L�ANT INFORMATI N: <br /> Name: �` <br /> w , �L ' �"f"�`',;' �;, /��,���.. <br /> State License# ' Expiration Date: <br /> Lead Certification Numb r: Expiration Date: <br /> (for work on homes that►Kere c nstructe ,prigr to 978 <br /> Phone: (cell) ���� � �'� ��-� �� (o e)�,.���� � �� ����� —�� �� <br /> Mailing Address: � � pj� " 'Z City: � �t( <br /> Contact Person: � /� �( L�Applicant is: Contractor / /Ho�me'owne� �,(Circle One) <br /> Email and/or Fax: T, �,F-� � j �1� —� <br /> , <br /> PROPERTY OWNER#IN—FORMATION: y�r, '�� � / <br /> Name: ` "J v� `- J�� �U�'���,�`c.'"v� <br /> Phone (day): � �Z . ��? � ��, � ��� <br /> Address: � City: � ZIP: ��' <br /> Email and/or Fax: � "� f �aJ � , � <br /> PROJECT INFORMATION: Overall project description: /�� � / /�f� <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt epair ❑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) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.ora <br /> Estimated Construction Valuation of Project(excluding land) $ <br /> APPLICANTACKNOWLEDGEMENT: �filNr�I�iNC - l 75 s�` �t °� �lI.3Sy-t� G��SCi���n� <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 enerally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is info whi ally ot be given to eit r.�he public or the subject of the data. Our purpose and <br /> intended use of this i ormatio is te o records an cords of other governmental agencies required by law. If <br /> ou refuse to su I the inform tion e a tio ma e i <br /> Applicant's Signat . �- • � • <br /> Owner's Signatu � �-- ...., D e: I(n <br /> Last Updated:January 2 6 O � //n � � � � <br /> � 1(./ � � �'��� ( ! `C <br /> � <br />