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Dec 17 14 12: 50p Victor & Kathy Barke 507-625-3343 p. 2 <br /> City of �rono <br /> Building Permit Application for Maintenance / Rep{acement / Renovationl� � i j s� <br /> (N o s t r u c t u r a l e x p a n s i o n. O n l y w i ndows, doors, siding, re-roof, etc.) <br /> ,: O,` <br /> Mailing Address: Permit number i��� �L'� �'� `-� <br /> / Q PO Box 66 � <br /> � �Q Crystal Bay,MN 55323-0066 Date received: r� Z � <br /> F�M�� ,�r� <br /> Received by: L—�' <br /> StreetAddress� �.r /oJ� <br /> -� � 2750 Kelley Parkway Plan reviewfee: ��� ~ !i��'"-``�'` - <br /> �^ � Orono,MN 55356 -s� � 3 <br /> \F s F���L'� Total Fee: '���(�;, <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> 7his application form must be completed in full and all required information must be submitted. <br /> Incomplete application�will be returned. (Please print) <br /> GENERAL INFORMATION: , � ' � <br /> Job Site Address: �� �'� �� � '�>� � '1'�U� � <br /> p y ❑Yes �No <br /> Will this be a Parade of Homes, Remodele s Showcase Home or ot e Dis la Home? <br /> If yes,a special event permit is required with Police DepaRment and City Council approva!60 days pnor to the event Shuttfe bus service wilf be <br /> required un(ess applicant demonstrates suilicient on-site parking is available. Non-permrtted events wil!not be allowed. <br /> CONTRACTOR/APPLICANT INFORM{A� TION: <br /> ��`,�� U C1,a;10 `�"1�`�'1 �i-�4��^m.�� — <br /> Name: �c- - - <br /> Expiration Qate: - 3�- <br /> State License# � ��� �J Expiration Date: -1 p <br /> Lead Certification Number: �'`('�ti `p�(�t,�l ' - J <br /> (for work on homes Ehat were constructed prior!0 1978 ,� �;� _ � ��J <br /> Phone: (cell) (oifice) C tZ � � � � � <br /> City: "`�'�6,Y'�'`Gl.t[��P- � � <br /> Mailing Address: ��"r>rJ�� . !'� "� L�'`� - <br /> Contact Person: - 1F_ Applicant is: on rac o / Homeowner (Circle One) <br /> . � y � �, _ <br /> Email and/or Fax: � ,�; r � �a � t,^�.��.�;�' ' � ' �M�l 0^n"S- ,C`_�'���--- <br /> PROPERTY OWNER INFORMATION: <br /> Name: 1��\1 � X �L <br /> ( v)� _ � - '� ' ��`". <br /> Add ess a ')j�V �� . . " *z tn r , �� City: �i r Cst,'1�_(�. ZIP: ��.��D��" <br /> Email andlor Fax: <br /> � , (�����/�<.i1��., <br /> PROJECT INFORMATION: Overall ro'ect description: � .,4_t ��J L��� �-- �"�"' <br /> Type of Project: Any earth movem nt may also require <br /> fJICWD review&permits� <br /> ❑Door(s) ❑Remodel ❑Fire Darnage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt �Kepair ❑Storm Damage �gzp2 Minnetonka 61vd <br /> Restoration ❑Water Damage Deephaven,MN 55391 <br /> ❑Re-roof,cedar ❑ phone: 952-471-0590 <br /> ❑Re-roof,other(specify) ❑Siding ❑Other(specify} Fax: 952-471-0882 <br /> ❑Window(s) (�(_Lt9'J�� �'��'�' www minnehahacreek.orq <br /> r���, _1 <br /> Estimated Construction Valuation of Project(exctuding land) $ <br /> APPLICANT ACKNOWLEDGEMEN7: <br /> . Agrees to provide all information required or requested by the Buifding Department; <br /> Certifes that the information supplied is true and correct to the best of hislher 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 afternative 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 inf ation which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this i form`�tion is to annu Ily update our records and records of other governmental agencies required by law. If <br /> you refuse to su 1 e inQormation,the ap icatro ma not be issued. <br /> ,,{ r _ � �1 .. l'� � ' � <br /> Applicant's Signature: r 9�l���- � � Date: T � <br /> Owner's Signature: Qate: <br /> Last Updated:03/06I2013 <br />