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• . <br /> City of Orono <bI. <br /> ' Building Permit Application for Maintenance / Replace / Remodel���I� <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �O� Mailing Address: Permit number: 20 L S–OU—1 AL1 <br /> O PO Box 66 • I <br /> Crystal Bay, MN 55323-006 3, Date received: LP /c <br /> Street Address: -1" / f° t <br /> ' G4' 2750 Kelley Parkw 1q5 Plan review fee: a! .LO _• a <br /> �gkESHO�� Orono, MN 55356 Z 0 1 5� <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) <br /> GENERAL INFORMATIONS / <br /> -� <br /> Job Site Address: �t 7-H0 wh1 (- Ly.. circ_I-� . (��'Jn0 (r)Ai 5 , 5�C <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other D{splay Home? ❑Yes 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 s is ' be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will n flowed. `e <br /> CONTRACTOR/APPLICANT INFORMATION: _._— <br /> Name: / ✓ge if r0/'IS 7SZCC n oki l_!J ` -1 L - Z �/J f7 <br /> State License# L •l d .. 3 Expiration Date: 3 f 3 j , a 0 1 7 <br /> Lead Certification Number: N AT-5 '3-3 -_� Expiration Date: �71 J i ] aD a C.. <br /> (for work on homes that were constructed prior to 1978 I <br /> Phone: (cell) 95 j, -3 3 Li_ .34 1 (office) 6, /a-s'd.5 as-lj Cj <br /> Mailing Address: 50 /1/,' City: rn A ,G( //S 5, 3 5 7 <br /> Contact Person: �� f S ZIP: <br /> ► e i�U e • --i7s=e f Applicant is: cntractor Homeowner (circle one) <br /> Email and/or Fax: bre i v, p Q - f5-€4 I aCc /nil i ( D)1n <br /> PROPERTY OWNER INFORMATION: <br /> Name: 'PO�I and INFORMATION. <br /> ec'} --e rre ) <br /> Phone(day): G 1 a_ `?1-IO -V �5 <br /> Address: a--7`f i01,0 '}e_.- oc Cy'!c_fr City: (517'070 ZIP:5J 3 <br /> Email and/or Fax: <br /> N// <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) 0 Remodel 71 Fire Damao MCWD review&permits: <br /> ❑ Re-roof,asphalt 0 Repair • Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ,'Restoration (Water Damage Minnetonka,MN 55345 <br /> 0 Re-roof,other(specify) 0 Siding �❑` er: (specify) Phone: 952-471-0590 <br /> -0682 <br /> 0 Window(s) (5'eeairh1E1l Fax:www.m952-4innehahacreek.orq <br /> / www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project (excluding land) $ '14) a 43' 3 3 - <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 suppi ,th- ' ormat in, - appl' a'.. ., - ' sued. <br /> jiipApplicant's Signature: _. Z:' _...i../ i / Date: • i * o2 O <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />