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m:Auben Residential To:Waliander Permit Application(19522494616) 14:14 06/23/11GMT-05 Pg 03-03ARIZ ., <br /> Cit of Orono <br /> Y ex... Man 6127 <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof,etc.) <br /> Mailing Address: 'deft" Q 6,57 2 <br /> ,��\ PO Box 66 Permit number: <br /> 0\1 Crystal Bay,MN 55323-0066 Date received:. . 69/A3 <br /> �� w,,. ' Received by: , <br /> Street Address: <br /> ��� �1 * 2750 Kelley Parkway Plan review fee: • <br /> �yk Orono,MN 55356 <br /> E7SHn,S <br /> Total Fee: /96 .7 <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: 1030 Wt//ow 14 n <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? 0 Yes Q'No <br /> N 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 I FORMATION; <br /> Name: /1 UhPxt 4(ees l,.A'la`i r i <br /> State License# ...?()(p 3Y Lp 17 Expiration Date: 3%3/b /3 <br /> Lead Certification Number: /A-I—_ d.9�"/ Expiration Date: 3i)cj/x01,5 <br /> (for work on homes that were construct prior to 1978 <br /> Phone: 9(. 07--1p57-aS(o5 (office) 9507-745-027,55 (cell) <br /> Mailing Address: ; 0 2 31 City: cam._ZIP: \,\S3S(o <br /> Contact Person: Jrirprny Koh Applicant is: Contractor / Homeowner (circle one) <br /> Email and/or Fax: e y • • • 1' • <br /> PROPERTY OWNER INFORMATION: <br /> Name: La(JffL. Wtz larder <br /> Phone(day): (m oZ - ez ' `f <br /> Address: /030 Hli 1/o'tA/ ✓/eW Z-V- City:Orono ZIP: ,5536( <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door(s) 0 Remodel 0 Water Damage MCWD review S permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) 0/Repair Storm Damage 18202 Minnetonka Blvd <br /> ❑Siding 0 Restoration 0 Other.(specify) Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> L7 Re-roof 0 Fire Damage Fax: 952-471-0682 <br /> www.m inneha hacreek q rq <br /> Overall Project Description: •i i , stor A( •/' I .• s n z utt-eis <br /> Estimated Construction Valuation of Project(excluding Ian i $ JO 000 <br /> APPLICANT ACKNOWLEDGEMENT: a... <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 <br /> are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative <br /> but to 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 <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re.uired b law. If ou refuse o su•.I the information the a••lication ma not be issued. <br /> Applicants Signature: <br /> Pp 9 . . /i._ .i .dkr%.tn(,d ill Date: JI//2 073 a.011 <br /> Last updated: 03-01-2011 <br />