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1213112015 10:32 (FA}() P.0011001 <br /> City of Orono # / g01.5$ <br /> Building Permit Application for Maintenance I Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> oA Mailing Address. Permit number: C�}e9/5 D/4707 <br /> ...:04. <br /> PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: /,3— <br /> Address: Received by: e /'- <br /> Street�' 2750 Kelle Parkwa <br /> Kelley Y Plan review fee: <br /> Orono, MN 55356 �� <br /> tKESHoa Total Fee: / ! /,'#/ <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.erono.mn.uit I <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: 1-30 r�,,ePlace) <br /> Job Site Address: (Y lm <br /> Will this be a Parade of Homes, Remodelers Showdase Home or other Display Home? -U Yes ...1k7 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/APPLIqANT INFORMATION: <br /> Name: _ i< v,4Ch f)( -6 <br /> State License# y'>5i33 Expiration Date: I • / , <br /> Lead Certification Number: /VA-r — --2q3 .3. _ Expiration Date: i0/070/c20 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) 6/Q--da(v .34 ( (office) 1051 -, t - , <br /> Mailing Address: ; , , OI / rs.mi City: I/ . ZIP: V07, <br /> Contact Person: 51-61,--e._ •SS Applicant is: 4011tfE C* Homeowner (Circle One) <br /> Email and/or Fax: (l7/44Li-13ge <br /> • <br /> PROPERTY OWNER INFORMATION: <br /> Name: 1-411 Wart _ <br /> Phone(day): qC — (JitoD—Le q/ <br /> Address: j' 31 ice! , ?la - City: i ail ZIP: b <br /> Email and/or Fax: P <br /> PROJECT INFORMATION: Overall project description: )t ' dee& i ?clr)S • h s-ct /UAa (r te'rsem <br /> Type of Project: Any earth movement may also require �'" '-J <br /> El Door(s) 1:1 Remodel ❑ Fire Damage MCWD review&permits: LA—, - <br /> 0 Re-roof,asphalt LI Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar El Restoration jgrWater Damage Deephaven, MN 55391 <br /> El Re-roof,other(specify) ❑Siding IDOther:(specify) Phone: 952-471-0590 <br /> Fax: 852-471-0682 <br /> ❑Window(s) _ www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $, 3 <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 supplytheinformation,the application may not be issued. <br /> Applicant's Signature: (73i 0011.4 +`. Date: /c3/3//6 <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 �� ��c�tel/ 7 (VI� <br /> P r i OP6Cla eC 1 0 r 1 ;"3/( 1 <br />