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. r , City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc. 2 <br /> �O�V Mailing Address: Permit number: DID/ 1 2 <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 7 <br /> Street Address: <br /> Received by: 4'1 L 0 <br /> A �` 2750 Kelley Parkway Plan review fee: <br /> `� Orono, MN 55356 <br /> ��K@SHc�� <br /> Total Fee: fi C,�j3 gs <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 pr. t) v <br /> GENERAL INFORMATION: <br /> Job Site Address: t 1 2 lA (it)e. /g(k U J G <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes Plislo <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 I APPLIgIT INF RMATION: / <br /> Name: T Ertc�Sp n <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructedr� prior to 1978 <br /> Phone: (cell) 672 7 9 0 2_3 -2 (office) 163 ({7 3 35(9 9. <br /> Mailing Address: A y$ , ged06(r„k jet/ City: ,47-,,, 4 he ZIP: 5-5-35-6Contact Person: 'r Applicant is: Contractor' / Homeowner (circle One) <br /> Email and/or Fax: e rt. .SQ,., .9 y jov . Cc:,-)✓A- <br /> PROPERTY OWNER INFORMATION: / <br /> Name: 7'rct E rfcicLSori <br /> Phone (day): C/2 if 5'0/ .23 7 ( / <br /> Address: .2t18 rn / ee.04 k 40/ City:J 7 4(� ZIP: S5 y3-6, <br /> Email and/or Fax: 0 . 7G 3 ct 3 0 1c <br /> PROJECT INFORMATION: Overall project description:_ <br /> Ty a of Project: <br /> 4 Any earth movement may also require <br /> oor(s) emodel Fire Damage MCWD review&permits: <br /> El Re-roof,asphalt Repair )0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> 0 Re-roof, cedar aestoration OWater Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other(specify) 411Siding , )Other: (specify) Phone: 952-471-0590 <br /> f--- <br /> fi Fax: 952-471-0682 <br /> OV1/indow(s) PLS www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ ,2 S[- <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 informs' t),••.lication ma not be issued. <br /> Applicant's Signature: Date: 7 1 <br /> Owner's Signature: —, - ' <br /> Date: 7/77 /y <br /> Last Updated:03/06/2013 <br />