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<br /> � . City of Orono 9� �• ��
<br /> �Building Permit Application for Maintenance / Replacement / Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> �O ` O Mailing Address: Permit number. c�C>� �- - L''�;C� �7
<br /> I�T PO Box 66
<br /> Crystal Bay,MN 55323-0066 Date received: �v-��-/
<br /> Sheet Address: Received by: �Y1�L
<br /> y �' 2750 Kelley Parkway Plan review fee: ��j .3 ��
<br /> �1RkESFia� G Orono,MN 55356 C �G��
<br /> �. � /C/—
<br /> Total Fee: C
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � 1 I���
<br /> This application form must be completed in full and all required information must e submitted.
<br /> Incomplete applications will be retumed. (Please print)
<br /> GENERAL INFORMATION: ,�_,
<br /> Job Site Address: 4�-1'r3J s_� ' �+�1�„ �J, �`�'G=��a'`� P�'�tJ
<br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? ❑Yes � No
<br /> !f yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be
<br /> required un/ess applicant demonstrates s�cient on-site parking is available. Non�ermitted events wil!not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> �
<br /> Name: Cs7���1� J�,�-!c� �s.�,7�:��:;�+J
<br /> State License# ��,=�����t�� Expiration Date: 3 p 31 r m�
<br /> Lead Certification Number_ Expiration Date: �
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell)(fo`�i� C9�,Lj'°�r a��, (office) �r io31 �`Z�i �`?i� �
<br /> Mailing Address_ �i r�� ���,� .��• City: MA��� ��q�� ZIP: �j5�Gj�
<br /> Contact Person: ��� ������,�g��„�� Applicant is: on �ac / Homeowner �a�ie a,e�
<br /> Email and/or Fax: �,�s�^0���-�A��,.f:� / ( ���,1 �`;w � .�E�.`iC
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: i o►� `a' �� �, ���..�i_E,F-,At.j,� r.}�.�
<br /> Phone(daY)= �'ar :_� n �`, J `i�t i
<br /> Address: ��1K� (�� ,,�,�� �J C�y: %�c._L�1.�U ..,* � ZIP: ��`�J CJ Lv
<br /> , -
<br /> Email and/or Fax: �L G��R,RR�FJD�U�t'�, CrMA��i-•��1
<br /> pJc,.J. f'a�5�1��,, <,1•,.t�7� 5�,,;pr;•, ._
<br /> PROJECT INFORMATION: Overall pro�ect descnption: Rt;'Mbpc:�- �A'R-N �1�- �I�- z'.q-�e-� * t�,���_i�
<br /> Type of Project Any earth movement may also require
<br /> ❑Door(s) f�]Remodel ❑Fire Damage
<br /> MCWD review 8�permits:
<br /> �Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 18202 Minnetonka Blvd
<br /> ❑Re-roof,cedar �,Restoration ❑Water Damage Deephaven,MN 55391
<br /> ❑Re-roof,otf�er(speciiy) ❑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) $ r)t�-�
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Depa�tment;
<br /> • Certfies that the information supplied is tn.ie and correct to the best of his/her Imowledge. 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 altemative 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 suppl the information, plication ma not be issued.
<br /> ApplicanYs Signature: / Date: '��I!=�� �i{
<br /> Owner's Signature_ Date:
<br /> �ast uPaatea:osrosrzois
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