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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> f A, Mailing Address: Permit number: &&I /-OL ni3i <br /> W <br /> Crystal Bay, MN 55323-0066 �1 Date received: / /'-! <br /> Street Address: Received by:2750 Kelley Parkway q A Plan review fee: an ,5 7'1 76Orono, MN 55356 '12,,i i 0?e)7�{_c700.57 <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 INFORMATION: _ <br /> Job Site Address: (7 L/Ltl T OAK Cvt(LL OgCiwo/ 5,S.SS 6 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display 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 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: ' CCK/CCN") _ LI. -t I'&-/ZS, r/VC.-, <br /> State License# eCOD 17 a 7 Expiration Date: 3731/4)-- <br /> Lead <br /> /3//iLead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) 6a_3y__f36 (office) s _ d'8-,22aa5 <br /> Mailing Address: ( o I EAST 7b' S . City ip.i, z -Toy(,ZIP: SS , .0 <br /> Contact Person: .T ftzeZ-7S (4446-s-Z Applicant is: (Contracto / Homeowner (circle one) <br /> Email and/or Fax: .-1--44,_,,,b a p� —��jcke' 'io/, Cc'v1 <br /> PROPERTY OWNER INFORMATION: is <br /> Name: ({0(Z `)- k� Zrn/ isegiicEa <br /> Phone(day): 93-02_ 9-L1 If a0 <br /> Address: Q79-0 L✓tfjTE OAK CTT12LLE City: 0ItbG1/4)C ZIP: „5.S 35 <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) Remodel 0 Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt ❑ Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar 0 Restoration 0 Water Damage Deephaven, MN 55391 <br /> ❑Re-roof,other(specify) 0 Siding 0 Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> 0 Window(s) /ASr:MEn/T- www minnehahacreek orq <br /> Estimated Construction Valuation of Project(excluding land) $ 77,, i QG <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 information,the application may not be issued. <br /> 2./iiii..4 <br /> Applicant's Signature: ____...i,� Date: <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />