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10119/2016 09:53 Dercon Construction (FAX)7639513019 P.002/003 <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel -ResSidentiatl-OI SLY <br /> (i.e.windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSION) <br /> oW <br /> Mailing Address: Permit number. C I(o-6.13 5 I <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Rece1V6d by: . G <br /> 2750 Kelley Parkway Plan review fe [� <br /> Orono,MN 55356 <br /> tEsrtot� 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: 06119 LO\.\\C L ) , <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes o <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus se ice will be <br /> required unless applicant demonstrates sucient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: 72112.AteiNeN. ;UJ) <br /> State License# cl,C,r31a4't i� Expiration Date: 3 -3 <br /> Lead Certification Number: )-C 3CAS Expiration Date: 1 - :_( <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) a") \-g � j j (office) fQ 1 �- o�`Z k2^1000/-0 <br /> Mailing Address: -1-3.1 i-)o-_ Lew, �; City: fid)ti,eA ZIP: 5 5,3,E zj <br /> Contact Person: v.e.,x,cx. fywort, e Applicant is: o ctor / Homeowner (Circle one) <br /> Email and/or Fax: Sr-z_vr\ekVlCs2 . u :� `4'c , 5•�. 1 Q3-ci S i-'.311 Il i <br /> PROPERTY OWNER INFORMATION: <br /> Name: r DO t.__Yr.mow. <br /> Phone (day): 44;1 - id3 rt gin'3 <br /> Address: Octc\ \-.1,5 \IDA . _ City: 4 ZIP: 5-536t I <br /> Email and/or Fax: nc4c,nom-c, e <br /> PROJECT INFORMATION: Overall project description: ,,1� - t`c?_;D� )��}� �� T <br /> Type of Project: Any earth mover t may also require` ' <br /> ❑ Door(s) ❑Remodel 0 Fire Damage MCWD review&permits: <br /> ORe-roof,asphalt Minnehaha Creek Watershed District(MCWD) <br /> p Repair LI Damage 15320 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> El Re-roof,other(specify) ❑Siding CIOther: (specify) Phone: 952-471-0590 <br /> Fax: 95271-0682 <br /> 0 Window(s) www_minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 9a 5 <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 rno <br /> efuse to supply/the Information,the a ['cation may <br /> ppt be <br /> 4 issued. / <br /> Applicant's Signature: 'r //� t e• Date: -/q-e(, <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />