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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> O�O Mailing Address: Permit number: 2,o/3- 6/Z73 <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: t� ,II'I Received by: S <br /> ti 2750 Kelley Parkway Plan review fee- <br /> KFSHO�� <br /> Orono, MN 55356 <br /> 9 <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: 11� <br /> Job Site Address: /46 lly meve F07 <br /> Will this be a Parade of Homes, Remodeler Showcase Home or other Display Home? ❑Yes ® 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: C�t.ar�eS Cv�c� Do-"o LLC. <br /> State License# [3C G35-Z45' Expiration Date: 0,3/3 t 201 S' <br /> Lead Certification Number: 9_Z— 30 358- 11 — O 1310 S Expiration Date: p Z 2 5/1 b <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) to12_ 88q- 46394 (office) (012- 359•- I-T39 <br /> Mailing Address: 156 Go 23 Ave. /l(ar City: ( 1,,mou ZIP: 6-'54%47 <br /> Contact Person: -J)-,v Lt l LLsve Applicant is: (Contract) / Homeowner (Circle One) <br /> Email and/or Fax: 1trn( Le c_ka-Y Sctrc� •Gorn� Fc1Zc X 12^loo�f -1239 <br /> PROPERTY OWNER INFORMATION: <br /> Name: +est it rort�'c�¢ <br /> Phone (day): (01?-- 4131- 11)4 II <br /> Address: // f5 erc acJ City: �Va Za a ZIP: <br /> Emailand/or Fax: Q,(l, Qr¢. he.vlcaQmai . cow• <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt ® Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ® Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) ❑Siding ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Estimated Construction Valuation of Project(excluding land) <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 th ' ormation, eADplication may not be issued. <br /> Applicant's Signature: OV1141.daDate: /� <br /> Owner's Signature: Date: (Z/ l! �ZO/ <br /> Last Updated:03/06/2013 <br />