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)0 / <br /> City of Orono , 5c/"� g� <br /> .Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSION) <br /> Mailing Address: Permit number: op C9 /(o-or-)�3 <br /> PO Box 66 R <br /> Crystal Bay, MN 5532 Date Date received: -�0 <br /> Street Address: FEB 10 2016 Received by: YI'1 <br /> 2750 Kelley Parkway Plan review fee: <br /> L �') Orono, MN 55356 CITY OF ORONO a <br /> SHO � <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) l <br /> GENERAL INFORMATION: <br /> Job Site Address: 7 OkkA W 1 )Z01 A <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ElYes No <br /> If 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 unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# I?G O0 57W Expiration Date: <br /> Lead Certification Number: /,/q.T. - 0.5 Sjs _/ Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) 612- .2�2_/ 0 g y/ (office) G/Z. 8L7- y ySS <br /> Mailing Address: , City: /tet/ ZIP: SS i <br /> Contact Person: pee& W se c_t., Applicant is: on rac o / Homeowner (circle one) <br /> Email and/or Fax: pe,* jz� wGK-41 E042-4 <br /> PROPERTY OWNER INFORMATION: <br /> Name: fu u F /320-J^l a' 54A4 N 13 0 X-M A/ <br /> Phone (day): 6 iL - 353- y 9zo Cg ec p e rC-r) <br /> Address: 75'5- 7vti,<4W4 1.2t)44 City: 0 40"o ZIP: SS 35i <br /> Email and/or Fax: re PK ARCH GO^t (i/2cvrrC_r7 <br /> QN4*P.4Cf4__ /G6fuVert— <br /> PROJECT INFORMATION: Overall project description: AL.4 rx(r J � pw a».cr ��•c.�. re y r <br /> Type of Project: Any earth movement may also require c rc <br /> ❑ Door(s) © Remodel ❑ Fire Damage MCWD review&permits: c-vH WWIWAS <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> El Re-roof,cedar 15320 Minnetonka Blvd <br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.ora <br /> Estimated Construction Valuation of Project(excluding land) $ 2 rJU, D04 - 40 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her 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 alternative 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 governmental agencies required by law. If <br /> you refuse to supply the i orma ' application may not be issued. <br /> Applicant's Signature: Parse- J- G>e7,o Date: <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 oc <br />