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, 'cil`' 41, 9 Vi°5 <br /> City of Oronb ,,i <br /> Building Permit Application for Maintenance / �teplacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O'V Mailing Address: Permit number: 620(3-01 V.q <br /> PO Box66 <br /> Crystal Bay, MN 55323-0066 Date received: I(-14 -(3 <br /> Street Address: Received by: S <br /> y 2750 Kelley Parkway Plan review fee: c7O(3—01 ZI g <br /> Fe C� Orono, MN 55356 X57 S3 <br /> kfsHo <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:INFORMATION:, <br /> Lu\lkocY1;,C\ CL. LOQ Long, LAK( )1Y\ eto <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other DisplHome? ❑Yes [q 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: CI( ' .(1 a(\ i �(at <br /> G\g. `0 n1 <br /> State License# U 3�( j2j 1 �j3 Expiration Date: (5(t ay 14 <br /> Lead Certification Number: 1,4AT s%A1g- I Expiration Date: 6:70c1 a015 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell)-iO3 .aa-j -q 505 (office) 103 -7 gc.3 --qtobd <br /> Mailing Address: -,Wag 0/ ` (c�/jk C,4 P' 416E City: ZIP: 6643a- <br /> Contact Person: R (A`( "RoTAIX Applicant is: ntrac O Homeowner (Circle One) <br /> Email and/or Fax: fh4-�te, w-ec 1 'UQd(N G6CQ- , g.,dr ei iGoS " 1Q1e) " 4'4)3 <br /> PROPERTY OWNER I`N�FORMATIONN:_^�,� <br /> Name: N-€1"1,( (1 .CXX�ct, <br /> Phone(day): toW -'3o q - 'i aQ <br /> Address: c.: y3 (.,S0,`6(1,`-)Cl g'-. KOCth City:LO(\aL Q. ZIP: 46366Email and/or Fax: KinA, ja.0 Yee ,(pm <br /> ( ,C OS6-- C.((��,,t,c Q-01-A.,- i+15J14k,o(l 1-o(Q.,AtcS�ocu.w .. w 5 , cwk6c AtiN 4" Rt3 OnF L� tote, <br /> PROJECT INI RMATlON: Overall project description:tMi)L t'.Oo -ike41 �C. ono6 ['l_C4j t( ‘cvt r OC t- <br /> Type of Project: An earth ovement may also require(4-k0( <br /> ❑ Door(s) ❑ Remodel 111Fire Damage MCWD review&permits:`, k u)&'...) <br /> El Reroof, asphalt El Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration KWater Damage Deephaven, MN 55391 <br /> El Re-roof, other(specify) ElSiding ❑ Other: (specify) Phone. 952-471-0590 <br /> Fax: 952-471-0682 <br /> LI Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $di I_SO <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 • .• ormation,the application may not be issued. > <br /> Applicant's Signature: " I . r _Aka,.. Date: '/" /d — 13 <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />