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City of Orono <br /> , Buiiding Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O ` -O Mailing Address: Permit number: / !�97 <br /> !V Po BoX ss o <br /> Crystal Bay, MN 55323- 066 � Date received: O '-1 S �/� <br /> Street Address: ��0, Received by: �)'�� <br /> y G� 2750 Kelley Parkway Plan review fee: � �.3, � <br /> `� Orono, MN 55356 <br /> lqkESH��� 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 /> Job Site Address: � / S� � �� .Jl ;� • �.c� /'v.� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? � No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the vent. us service wi//be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitt nts ill t llowed. <br /> CONTRACTOR/APPLICANT INFORMATION: � ` <br /> Name: {� ,'' -�v�. �I� r✓►�c�, <br /> State License# � ('d 9 (v xpiration Date: 3 � v/ <br /> Le�d Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) l� � S - D=2 ( ice) --� <br /> Mailing Address: ,,. ,� City:md„{;r��/ Z�P: ��3 (�,2 <br /> Contact Person: 1�,1i,� plicant is: ontrac / Homeowner (Circle One) <br /> Email and/or Fax: <br /> �' <br /> PROPERTY OWNER INFORMATION: <br /> Name: �;�Q /!h,-�TS <br /> Phone (day): (D ��, � S 9�� - / 7 U <br /> Address: �Z,�S j��: ��� �,�e � �_ City: �y�-j�.,�, ZIP: <br /> t\/'t <br /> Email and/or Fax: ���.,��-�,,�,,���,�u;� , �,�,,,,.� <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review&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(specity) ❑ 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) $ `7S v[�v <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 /> ou refuse to su I th information,the a lication ma not be issued. <br /> ApplicanYs Signature: a,r�✓L,kX /– `Z�¢���v�-i Date: !�� " /S —-�D�� <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 C" �/ �rG/�� � �� �/n <br /> �v <br />