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City of Orono �� �• <br /> Building Permit Application for Maintenance / Replacement/ Remode — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> OA, Mailing Address: Permit number: a?_o/ - �,D,S <br /> !VO PO Box 66 5 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address. �(/�` 0 Received by: `yup <br /> 2750 Kelley Parkway Plan review fee: 7 <br /> F L <br /> `9kESH0�� Orono, MN 55356 b <br /> oi�- oa s7S <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: <br /> Job Site Address: /,. 5-0 wy, p ni 4F/e-f�' wa/7-p <br /> Will this be a Parade of Homes, Remodele s 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: /t 5T2 ef_r LLG <br /> State License# 4 C 3 Qp 9�1� Expiration Date: <br /> Lead Certification Number: 1Vi?7✓: Z9<c+3� 2_ 7Y-FRIc AJ �.v7-:Expiration Date: Zg2o,Zc, <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) Z a 7-0 r0 0 Z (office) <br /> Mailing Address: ( Q a cit : ZIP: <br /> Contact Person: tc L Applicant is: Contra / Homeowner (circle One) <br /> Email and/or Fax: lc 3' V✓/)� � j'�/y/Fj C o�-v. <br /> PROPERTY OWNER INFORMATION: <br /> Name: 1jt$�(G ef- ,Fara <br /> Phone (day): g Y-2 9 X41 1(4- <br /> Address: (( w(ImJ/1 w O✓40 City: ,O/�a,'J (D ZIP: .s'j'�}'} <br /> Email and/or Fax: SV-RRuti5 EL (I "90LJ a_T . LAr-- <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: EK <br /> Any earth movement may also require <br /> [v"Door(s) LK Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ R'?0, ©CFO <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 cvnually update our records and records of other governmental agencies required by law. If <br /> you refuse to supp!y the.int@OatiorxYe application may not be issued. <br /> Applicant's Signature: Date: <br /> Owner's Signature: � Date: 1/22/11, <br /> Last Updated:January 2016 /� lel(` 11(e <br />