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� '�- <br /> City of Orono . <br /> �Buflding Permit Application for Maintenance ! Replacement ! Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> Mai7/nq Address: permit number: — <br /> �� . PO Box 86 <br /> � Crystal Bay,MN 55323-0066 � Date ieceived: <br /> Street Addr�ss: 1 Re�ed br <br /> ��, � 2750 Kelley Parkway 0�� Plan.review(ee: <br /> t �,L Or�no,MN 55356 � ' ��, �� <br /> �k s��� • Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4816 www.ci.orono.mn.us <br /> This application form must be completed in full and all requi�ed information•must submitted. <br /> Incomplete appllcatfons will be returned. (Pleese pdntj <br /> GENERAL INFORMATION: � , • . <br /> Job Site Address: 5 L 2� (��6�i ,"�d�. lU C.'c.;,,,�,: ►11.1 J� �`J���j�c� <br /> Will this be a Parade cf Homes,Remodelers Showcase Hame or other Display Home? Yes No <br /> lfyas,a apacie!ev�nt permAls roqu/rod w�h Poflce Oapartment and Cily Cwrncll epprova!80 days prtorto the ewent ShWtle brrt servFce wiA be <br /> nquked unksa appNcant demautrates s�icierrt on-a�+e paAang!s evaHable. Norr-penndfed sveMs wiN nof be sMowad. <br /> CONTRACTOR!APPLICANT INFORMATION: <br /> Neme: '�:�zu.; I�ucl�=b►�Ic[e'" <br /> State License# �,}/q Expiration Date: <br /> l.ead Certif�cation Number. u;;� Expiration Date: <br /> (for work on homes that were consHuc[oed prlor M 1978 <br /> Phorte: (C�if) 2.f$- 31L�-- 1�S"/�/ (offiCe} <br /> Mailing Address: ' ?Z.5 G, , �r ` City: �?r,.��• ZIP: • .aS ' 356 <br /> Conta�ct Person: 2:.,��„�; ?«rk k�lc�t- Applicant is: Contractor Homeowner'> �cu�i.o�.� <br /> Email and/or Fax: cQ n�, b�:K���I��c� �a��,•«�.�/ .. c'�;v, � - <br /> PROPERTY OWNER INFORMATION: <br /> Name: �f t c� �- f�-f�an<< ��.�k�<<^lcP��,/`�';rk� <br /> Phone(day): 2/�'- �/G�• l�!�7 S'S 3 56 <br /> Address: �� ZS ��.U, ,�},,�t J�f City: �r`.,,� ZIP: <br /> Email andlor Fax: �i'n�.�ic::k��le.k�•- C� �.,,�,�,;'/, eo,v, <br /> PROJECT INFORMA710N: Overall ro ect descri tion: k���1 r�1 !� '�'`R'���t� ��`�`�t �.�'t`�` <br /> Type of ProJect: • Any earth movement may also requlre • <br /> ❑Door(s) �Remodel ❑Fire Damage MCWD revtew 8�permtts: � <br /> ❑Re-roof,aephalt ❑Repair ❑Storm Damage Minnehaha Creek Waterahed DisUict(MCWD) <br /> � 18202 Minn�onka Blvd <br /> ❑Re-roof,cedar []Restoratfon ❑Waler Damage Deephaven,MN 55391 <br /> ❑Re-roof,other(spaclry) ❑Siding ❑Other:(specify} Phone: 852-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Windovu(s) www.minnehahacxeek.or� <br /> Estlmated Construction Valuation.vf Project(excluding land) $ ��'�Z-�.� <br /> APPLICANT ACKNOWLEDGEMENT: ' <br /> • AgreeS to provide aN infonmation required or requesled by the Building DepaAment; . <br /> • Certifies that the information supplied 9s true ar�d corred to the best of his/her knowledge. The appllcant recwgnizes ti�at they are <br /> solely responaibfe for submittir�g a oomplete appflcaiion being aware tt�at upon failure io do so, the sta(f has no altemaGve but to <br /> reject it until it is complete; <br /> • Some or all of the information that you are ssked to provide on this eppllcation is classified by State law as either private or' <br /> confidential. Private data Is Information which ger�rally cannot be gi�ren to the publ�c but can be given,to the subject of the data. . <br /> Confidenbal data k informatbn which generally cannot be given to eitFier the pubic 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 e�perklea required by law. If <br /> ou refuse to s ths' fo siti a lication ma not be issued. <br /> Applicant's Signature:;�—�. �l-"�--'� Date: ��� - / ' �Y <br /> . � <br /> Owner's Signature,�j�. � l .�=��" Date: ��'� �� ��� <br /> �esl Uptleled:03l06I2013 � <br />