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( 7-347gi <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. NO STRUCTURAL EXPANSION) <br /> t `Tr <br /> O - -, Mailing Address: Permit number: �/1-0/.1 <br /> �V �'. PO Box 66 � A _ —7 <br /> Crystal Bay, MN 55323-0066 101 Date received: O�3j / <br /> ' 0 b� Street Address: IN / Received by: <br /> Ye I IJ 2750 Kelley Parkway Plan review fee: 3cc, <br /> ` Orono, MN 55356 ` <br /> ,A sito"' / Total Fee: l-7 ^ 6/b/� <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 submitt''d c73ago>b <br /> Incomplete applications will be returned. (Please print) <br /> / <br /> GENERAL INFORMATION: <br /> Job Site Address: c,‘A.,-Ai a t ), 42-c`"4 01I'A ; t4 i SS S <br /> Will this be a Parade of Homes, Remodelers 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 servic'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: 23:TVP Pi-cm i Ct.- C""Cirk ircui Ct►N-r c\c-+ <br /> ! j <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) Intl- 3,t.6- 9,2_6) (office) <br /> Mailing Address: I-)tr- I I '1u-t'\ f\vC N City: tvlc k C10,-,r-t ZIP: mss-3i 1 <br /> Contact Person: M cn.v-}-A) 17.4.44-; G --- Applicant is: ontractor Homeowner (circle One) <br /> Email and/or Fax: , c& ICX ctoo C,� rrLmi c— cic.ir _v_co , at rte - <br /> PROPERTY OWNER INFORMATION: <br /> Name: Q-eplrv..o no( rc&rkl 1'j SOI'-.rt,n 1 of <br /> Phone (day): ((012) ' 5 0 '7015 <br /> Address: 531,1 $hu✓e I int Drive City: Ate LA.,4. ZIP: S53b <br /> Email and/or Fax: C(act 4 (w Ci rwt y !leek r Delet, co r-. <br /> PROJECT INFORMATION: Overall project description: office rt is ti I d. <br /> Type of Project: Any earth movement may also require <br /> CIDoor(s) [Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt CI Repair 111 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> E 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) 1 y'www:minnehahacreek.orq <br /> d <br /> Estimated Construction Valuation of Project (excluding land) $ 5b 1 y 14 <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 ca •t be-given to the public but can be given to the subject of the data. <br /> Confidential data is infor .tion whir •:nera ly ca •- •iven to either the public or the subject of the data. Our purpose and <br /> intended use of this info , at., i `o "nu.v.-.ate . ecords and records of other governmental agencies required by law. If <br /> you refuse to supply/,- orm.;i.• ..ica ' -.r <br /> on . ., not .- i =d. <br /> Applicant's Signature: Date: <br /> Owner's Signature: \ Date: <br /> Last Updated:January 2016 <br />