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To: Pnge 3 of 3 20'13-'1 0-08'12:04:00 C�T '19525'165440 From:Wayznta Corporete <br /> • \ <br /> City of 4rono � <br /> Building Permit Appifcation for Maintenance 1 Replacement / Renovation <br /> {No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> A, MaHingAddress� Permitnumber: /3l0�� <br /> �'-�1 V� PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: /�- -�.3 <br /> Street Address: Received by: <br /> � 2750 Kelle Parkwa <br /> `� G� Orono,MN 55356 Y Plan review fee: <br /> t"�KESt{OQ`� � ,,a� .�s <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 prinf) <br /> GENERAL INFORMATION: <br /> Job Site Address: ��� p.,�y/,t/U /( <br /> WIU this be a Parade of Homes,Remodelers Show se liome or other Display Home? Yes o <br /> !f yes,a specla/event perm�t 1s requlred wlth Police Deparlment and Clfy Counci!approve!60 days prla to the event Shuttle bus servic�e wll!be <br /> requlred unless a,npflcanl clernonsUafes sYrH)cient on-s7te p�rkl��g!s evallable. lJon-permltted events wil/nof be aUowed. <br /> CONTRACTOR/APP CANT INFORMATION: <br /> Name: ��t/p�C.�./ S'.ei1iJ'E� <br /> State License# ��_ F�cpiration Date: <br /> Lead Certification Number: r-- Expiration Date: <br /> (for work on homes that were onstructed pdor to 7978 <br /> Phone: (ce�q / �z 9r, (ot�ce) <br /> Mailing Address: ps-- S' City: ZIP: <br /> Contact Person: N�IGt'�✓ .C!°�L f Applicant is: Contrac r / meowner �cirde one> <br /> Email and/or Fax: �,q„/�,��,,. cl�l I't,� l� Qrtil .� [d� <br /> PROPER'fY OWNER INF RMATION: <br /> Name: �ir/G�77i✓ .�P,/.�lfi?� <br /> Phone(daY)- . . � <br /> Address: ,7.0 � CItY: �{/ 2 y.,� Z�P: �,� rs�7/ <br /> Emall and/or Fax: ,� �iv� �,,��•�, <br /> PROJECT INFORMATION: Overall ro'ect descrl tion: Si`� '�U <br /> Type of Project: My earth moverr�nt may also require <br /> ❑boor(s) LI Remodel ❑Fire Damage <br /> MCWD roview 8�permita: <br /> Mlnnehaha Creek Watershed District MCWD <br /> ❑R�roof,asphalt Repair ❑Storm Dc�maga { ) <br /> 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephav�,MN 55391 <br /> ❑Re-roof,other(specify) �]Siding ❑Other:(speafy) Ptione: 962-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.ora <br /> Estlmated Construction Valuation of Pro)ect(excluding land) $ <br /> APPLICANT AGKNOWLEDGEMENT: <br /> • Agrees to provide all Information required or requested by the Building Department; <br /> • Certifles that ihe information supplied is true and correct to the best of hislher knowledge. The applicant recogn¢es that they are <br /> solely responsible for submiitlng a complete application being aware that upon failure to do so,the staff has no altemative but to <br /> rejed it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classlfie�! by State law as either private or <br /> confid�tial, Private data is information which generally cannot be given to the public but can be given to the subJect of the data. <br /> Confidenti�l data is infonnation which generally cannot be given to either the public or lhe subject of the data. Our purpose and <br /> intended use of this information is fo annually update our records and reoords of other governmental agencies required by law. If <br /> u refuse io suppl_y the informatlon,the application may not be issued. <br /> ApplicanYs Signature: f Date: __lV. � ..�Ol� <br /> 0 <br /> Owner's Signature: Date: �), p� �GY� <br /> Last Updated�03/06/2013 <br />