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City of Orono c(7)� <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �o V Mailing Address: Permit number: p?(W��/ <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: c2 //��-yT <br /> Street Address: Received by: /'7'f� <br /> y� G� 2750 Kelley Parkway Plan review fee: <br /> t Orono, MN 55356 <br /> .1kEsHo� /_7.S <br /> Total Fee: "l etlD I <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 /> GENERAL INFORMATION: <br /> Job Site Address: J 7 u) Pi(2- Lfv S , 0 RO_-477 ,/)1 ,N) S 53 ,' <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes IV No <br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle buss ice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: _52ri c.) CO^'-f ra-vii XON SNC, r <br /> State License# .13C (03 4.511-t Expiration Date: <br /> Lead Certification Number: Ai 11 Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) 7 6, 3 — "3_1 1 — 7 S a al (office) <br /> Mailing Address: 7 35 n-- 5 ry k N City: ,. --' ZIP: S5 3 03 <br /> Contact Person: S �s-A,.) JcG ,1J Applican Contractor Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: Jo^1:= PF6a.-PGE2 <br /> Phone (day): -76S Zz.7-5(,` /CC <br /> Address: 7 O 64.161)(t- 1, N c, City: Z) ZIP: CS-3S& <br /> Email and/or Fax: j r r✓ 3f-1S ,2N 90 G m Art , c 0 M <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) XRemodel(tS ' ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt CI Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> 11 Re-roof, other(specify) 111Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Estimated Construction Valuation of Project(excluding land) $ L PPJ 000 co <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 tRi annually update our records and records of other governmental agencies required by law. If <br /> you refuse to supply th; Erma.q e plication may not be issued. <br /> Applicant's Signature: // , 1/ Date: aZ y 2 / L <br /> Owner's Signature: Date: c7// 2//y <br /> J <br /> Last Updated: 03/06/2013 <br />