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i <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> W <br /> Mailing Address: Permit number:PO Box 66 `�—/itCrystal Bay, MN 55323-0060 Date received:Street Address: Received by. <br /> 2750 Kelley Parkway ��� Plan review fe <br /> Orono, MN 55356 n . • <br /> kfsH0V. Y ,/ <br /> Total Fee: L Q "' <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us v <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 /> GENERAL INFORMATION: <br /> Job Site Address: 075 WR'/Z'kTA BLVD. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes RrNo <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: KRI1U4 A-Npt izs N toms7l-UGTION CO• <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (pi a- 3(ob- 7gg71 (office) &I - 335- 7,7.(.. <br /> Mailing Address: 5,7.5 SOUTH $+" ST. City:u/NNt,}PpL►S ZIP: 5 5q01 <br /> Contact Person: J i M $fes w,rH Applicant is: ntrac Ty / Homeowner (circle One) <br /> Email and/or Fax: J i►1Yi• li1Cc wi lilts Kira avute-i- o✓i. Lvw1 <br /> PROPERTY OWNER INFORMATION: <br /> Name: KQA J$ ANDEg-501 R€A-1-7y <br /> Phone (day): 952 - 881- 0/111 <br /> Address: yat)D W1;ST OLD 51til-kOrEE ROAD' City: 13.i:bDit1/N6TON ZIP: <br /> Email and/or Fax: nial ex&late&git.ned fy• Com <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) [Remodel IIIFire Damage MCWD review&permits: <br /> 1=I Re-roof, asphalt 111 Repair 111 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> 111 Re-roof, other(specify) [' Siding 111Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 03, ih90 <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 informal., that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data/is formation P. 'energy cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is informa on which.f ner• y cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this inform:tion is 'n .Ily upda our -cords and records of other governmental agencies required by law. If <br /> you refuse to,supply the ii f. matin .e a•,• 'cab. .•�not be issued. <br /> Applicant's Signature: (..4)77 - Date: /,, ' L/_ J L/ <br /> Owner's Signature: / Date: <br /> Last Updated:03/06/2013'/ <br />