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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> .-(i.e. windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSION) <br /> OA- Mailing Address: ZOI Theb J d <br /> PO Box 66 Permit number: <br /> Crystal Bay, MN 55323-0066 Date received: /ai/ l c <br /> Street Address: Received by: <br /> �� ` 2750 Kelley Parkway Plan review fee: //� <br /> �' Orono, MN 55356 "1 <br /> tdk@SH0' ("'25 <br /> Total Fee: (`"'2 U. <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 1J' <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:. J1 / J <br /> Job Site Address: /O w .✓ , //C9t,J V) 1r. Zd��j 4.1e--< <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other DispNly Home? ❑ Yes allo <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: 5tA-I1yz 7L 6uns.1CIA-C-4Ir.-, b cz�,/j� _fi'�C. <br /> State License# 69C_3 7 566, q U Expiration Date: <br /> 3- 3/ -/ 7 <br /> Lead Certification Number: /0/A riowK- gyt,:// ,i, ,200 / Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) 6,i a j66-..? 3 9 (office) 7 6 3- Se/(-//co <br /> Mailing Address: 5-/C/ AN/ Ss' 5-44,,4, 5-out) City: /J-J mi,,,�/,s ZIP: 515' %1 Z <br /> Contact Person: - -",;s-/ Let.. am n Applicant is: Contractor 1 Homeowner (circle one) <br /> Email and/or Fax: nLcs.c„.na,,r. e_s.unye. -1- Cpm. <br /> Of <br /> PROPERTY OWNER INFORMATION: <br /> Name: (--,'oj A4 a r ill s <br /> Phone (day): 6/07 -'2/ 2 -/557 v u <br /> Address: /O i,5 to)1/04t) c <br /> t), w 0 -, City: Zer-,q L ZIP: S$3,j to <br /> Email and/or Fax: d <br /> Oft <br /> PROJECT INFORMATION: Overall project description: L v <br /> Type of Project: Any earth movement may also r uire <br /> ❑ Door(s) 0 Remodel IDFire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD)1:1 Re-roof, asphalt Re air ❑ Storm Damage <br /> 15320 Minnetonka Blvd <br /> 0 Re-roof,cedar ❑ Restoration Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) g'Siding IDOther:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> 0 Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 4/D, Oc' ) <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 a plication may not be issued. <br /> Applicant's Signature: 571 Date: V----?9 -/ <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />