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ti � <br /> � . �� �o� �. <br /> City of Orono <br /> B iild g Permit Application for Maintenance / Replacement / Renovation <br /> o structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Pertnit number: f —� <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: "� <br /> Street Address: Received by: T'" <br /> � �` 2750 Kelle Parkwa �j <br /> y�. G Y Y • Plan review fee: � <br /> 4 Orono,MN 55356 a���_ <br /> fs �' � <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 print) <br /> GEN � NFORMATION: <br /> Job i e dress: 31 �5 SUSSe,x Road�� O�ono �rv1N 5535` <br /> Will h�s b a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If es,a cial event permit is required with Police Department and City Council approval 60 days prior to fhe event. Shuttle bus seMce will be <br /> required unless applicant demonstrates sulficient on-site parking is available. Non-permitted events will not be allowed. <br /> CON RA OR I APPLICANT INFORMATION: <br /> Nam : , WI A Pt�tu'son 'i�c.s�qr� '(3u,il�k <br /> State L�ce # �C 0067�`� Expiration Date: 03/�i/2oi� <br /> Lead rti tion Number: N qT_232 i7-� Expiration Date: �H/o$/zo i 5 <br /> (fo �or n homes that were consbucted prfor to 1978 <br /> Phon .� (cell) (office) as2-q25-q�is4 <br /> Maili iAd ss: (,I G 1 Wo aa�t l�vtnu�c. S oc�wa. City: E���+d ZIP: 55H2M <br /> Cont ct Pe on: �o�Y�F3irw.�a.+�9- Applicant is: ontracto / Homeowner (CircleOne) <br /> Email and/ Fax: ��. y;�ksla�i rr�o,.Pt,he.rs.n. c,or+�, <br /> PRO ER OWNER INFORMATION: <br /> Nam pV�0.f� �r �aw+ l�elmo�t <br /> Phon (�iay G�y2 ��3- u&t S <br /> Addre si: 3115 SuSStX '2oarR City: Oron�o ZIP: 553'f� <br /> Email rid/o Fax: <br /> PRO EICT FORMATION: Overall ro'ect descri tion: <br /> Type roj t: Any earth movement may also require <br /> ❑Do (s) � Remodel ❑ Fire Damage MCWD review 8 permits: <br /> ❑Re-�of,a halt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑Re- qf,c ar ❑ Restoration ❑Water Damage Deephaven,MN 55391 <br /> ❑Re- of,o er(specify) ❑Siding ❑Other:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.ora <br /> Estim ted nstruction Valuation of Project(excluding land) a 1 l 5 .ooe <br /> APPLI N ACKNOWLEDGEMENT: <br /> • A r�es provide all information required or requested by the Building Department; <br /> • C r�ifie hat the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> s lely r ponsible for submitting a complete application being aware that upon failure to do so,the staff has no altemative but to <br /> r e�t it til it is complete; <br /> • S rrle o all of the information that you are asked to provide on this application is classified by State law as either private or <br /> c nfide I. Private data is information which generally cannot be given to the public but can be given to the subject of the data. <br /> C nfide al data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> in nde se of this information is to annually update our records and records of other governmental agencies required by law. If <br /> efu to su I the information,the a lication ma not be issued. <br /> Applica Y Si ature: ��� y���Q Date: OG�?'j�2o/�( <br /> Owner' Slign ure: Date: <br /> Last Upda ed:03 /2013 <br />