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k_ . 505 <br /> City of Orono `J <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> ovation <br /> (No structural expansion. Only windows, doors, siding, etc.) <br /> Mailing Address: Permit number: <br /> QA, PO Box 66 <br /> W <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Received by: <br /> Street Address: <br /> ''S 2750 Kelley Parkway Plan review fee: �j <br /> Orono,MN 55356 �'✓kESHOTotal Fee: <br /> 1. <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: I op w Qs t aryi.) a <br /> Job Site Address: I iii <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? r]Yes Afillo <br /> epartment and City <br /> il approval 60 days prior to the event. <br /> If yes,a speraunless applicant demonstrates Dsufficient on-site parking iscShuttle <br /> avai able. Non-permitted events will not beallowed <br /> requiredservice will be <br /> CONTRACTOR 1 APPLICANT INFQRMATION: <br /> Name: 1 O'fnlj <br /> Expiration Date: 0State License# 1 I i.1 P Expiration Date: <br /> Lead Certification Number: <br /> Ni .. rim, A "` , <br /> (for work on homes that were cons ructed prior to 1978 (office) Ci�/f x I '1�2 <br /> AP <br /> Phone: (cell) <br /> Mailing Address: DO y St- It plc, ZIP: �jt7f�LO <br /> (�(� 0, , , <br /> it«tVy Elva Cit <br /> Contact Person: A A Applicant is: ontracto / Homeowner (circle <br /> Email and/or Fax: Q,Yti'PS� la von ;1 yj • (A ai • q2� <br /> PROPERTY OWNER,�t)IOV ATIONj .1 l i �� <br /> Name: 'JJ . VVI <br /> Phone(day): a ' -! • _ . City: 1/01/10 <br /> �,�j��.ZIP: 1- -- -,0q.10 <br /> ✓ ,0"� '-" <br /> Address: MO W' /. #'' <br /> Email and/or Fax: .r W ipi a m 2 V�ckO00 <br /> PROJECT INFORMATION: Overall pro'ect description: r. 4 A / i <br /> W•' v 'ea 'wmov• ent may also require <br /> Type of Project: MCWD review&permits: <br /> ❑Door(s) 0 Remodel 0 Fire Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt 0 Repair 0 Storm Damage 18202 Minnetonka Blvd <br /> 0 Water Damage Deephaven,MN 55391 <br /> ❑Re-roof,cedar 0 RestorationPhone: 952-471-0590 <br /> ❑Re-roof,other(specify) Siding 0 Other: (specify) Fax: 952-471-0682 <br /> dow(s) www.mi neha ac ek.orq <br /> Project(excluding land) $ LU9 V 0 V . <br /> Estimated Construction Valuation of <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 /> iven to the <br /> the subject of the data. <br /> conl Privdata ase data is information which genrmation erally cannot be given toch generally cannot be gether the public orc but can be the subjectven ofthe data. Our purpose and <br /> Confidentialn <br /> intended use of this information is to annually u•date our records and records of other governmental agencies required by law. If <br /> you refuse to supplyation,th- .plic• on - ay not be issued. <br /> Illir <br /> Applicant's Signature: mow A•- �A_ _ <br /> Owner's Signature: <br /> A.II Date: 1 • <br /> Date: <br /> Last Updated:03/06/2013 <br />