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7979 <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> O q ' Mailing Address: Permit number: a,(�I L( --O 17(07 0 <br /> / PO Box 66 <br /> * (4.1Crystal Bay, MN 55323-0066 Date received: 6-AO "I V <br /> Street Address: Received by: 14"°' <br /> 2750 Kelley Parkway Plan review fee: �/ <br /> /-r Orono, MN 55356 dY <br /> �1'Iil•C �t"� <br /> Total Fee: /05E.70 <br /> Main: 952-249-4600 Fax: 952-249-4616 - <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: /0 be 7 ,434- j4--3 /2 o4Q <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? D Yes IN 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: Ai S n?J 7— ilewl of r GL 'Q <br /> State License# $c 3 90 906 Expiration Date: 31,,,jzy/I— <br /> Lead Certification Number: A/,9- Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) Olaf 2 4 s--6 . 41 co-t_ (office) (42,vki t$S`0 • y are__ <br /> Mailing Address: iii4 e• w dip* fy L V' #20 i City: u�� ZIP:f 7 f <br /> Contact Person: 1jtk C, v f_- o,ie Applicant is: /(,`ontrac / Homeowner (circle One) <br /> Email and/or Fax: ,etC�L Li "crrtivAsrade7--///04t3. con.. <br /> PROPERTY OWNER INFORMATION: <br /> Name: h/6e 4,9,,•i i La-- <br /> Phone (day): (AL Z) S'/ i , /O/S"' 6 I1/Lf/ <br /> Address: /0 60 7'000. /'G44 City: o20N0 ZIP: J5S%'.?3 0 <br /> Email and/or Fax: L3l(L a. c Com- ,6—"7,47L • C0i?-N.. <br /> PROJECT INFORMATION: Overall project description: to uJ a. L-64144 ?E 4rildld,0✓4rjht( ' /SOP LQ&6 t <br /> Type of Project: Any earth movement may also require 2 L <br /> ❑ Door(s) !`i' Remodel E]Fire Damage MCWD review&permits: <br /> CIRe-roof, asphalt ❑ Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑Re roof, cedar <br /> ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑Re-roof, other(specify) ElSiding CIOther: (specify) Phone: 952-471-0590 <br /> 0 Window(s) Fax: 952-471-0682 <br /> Estimated Construction Valuation of Project(excluding land) $ y-c, Get <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 i to annly update our records and records of other governmental agencies required by law. If <br /> you refuse to supply the infor/. on,th/-�•pli -tion may not be issued. <br /> Applicant's Signature: _ , . Date: &'ft? /r <br /> Owner's Signature: \ 1106T '`-�—_ Date: 23/06/14 <br /> Last Updated:03/06/2013 <br />