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City of Orono <br /> Building Permit Application for Maintenance 1 Replacement / Renovation <br /> e <br /> (No structural expansion. Only windows, doors, siding, etc.) p <br /> Mailing Address: Permit number: /V�/1 C 9 <br /> V-O V PO Box 66 Date received: la-/5—/� <br /> Q Crystal Bay,MN 55323-0066 <br /> Received by: �. <br /> Street Address: <br /> *:".S.* <br /> t 2750 Kelley Parkway Plan review fee: <br /> �F ." Orono,MN 55356 . �� <br /> tRkESHO1t 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: 1 1 \M \ I Q\iU o r . �S. <br /> Job Site Address: 1 <br /> Will this be a Parade of Homes, Remodelers ShowcaseHomeor other <br /> aDi Display <br /> ys prom Home? <br /> event.1Shutt sous service ill If yes,a special event permit is required with Police Department andCity <br /> Council required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR 1 APPLICANT' IN_ FORMATION: <br /> Name: VV 0t)( <br /> State License# A00D 0G7: Expiration Date: 0 <br /> AT.j r Zt-7))4 <br /> Lead Certification Number: 7v� � Expiration Date: <br /> (for work on homes that were constructed prior to 1978 (office) 0 02. • a ' • ZZ <br /> Phone: (cell) <br /> 49 <br /> LIP <br /> Mailing Address: uo ,, <br /> L WY give City: sr Ig plc ZIP: Varrit1 <br /> Contact Person: A A Applicant is: ontracto / Homeowner circ) <br /> �. �. -V1( . cowl A • q22 .4111 <br /> Email and/or Fax: e1�P,S� ,�'.t 1A1/1H� <br /> Name: ) <br /> ERTY OWNER I Ot111�1AT1 V: 1 , tISO k <br /> j . <br /> Phone (day): / AIM • c�! r I--��/�A Q7IP: ' <br /> ' t 1 DA) r, J ' City: J A J..- IV l ✓4 <br /> ?��. <br /> Address: l ( <br /> Email and/or Fax: p�� ..(� 1(0.0.1)-f kiOu <br /> PROJECT INFORMATION: Overall project description:T '14)I 1 [ <br /> AIA-Elk <br /> Any earth movement may also re ire <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 /> Deephaven,MN 55391 <br /> o Re-roof,cedar 0 Restoration 0 Water Damage g Phone: 952-471-0590 <br /> ❑Re-roof,other(specify) 0 Siding 0 Other:(specify) Fax: 952-471-0682 <br /> 0 Window(s) <br /> min h �acreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ <br /> � ct Du . L � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; recognizes that they are <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant <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 u•date our records and records of other governmental agencies required by law. If <br /> you refuse to supply opation,th,rPIik <br /> on • ay not be issued. D lk <br /> �� <br /> ] 1 Date: <br /> Applicant's Signature: ...- •_a_ <br /> Date: <br /> Owner's Signature: <br /> Last Updated:03/06/2013 <br />