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. �J <br /> City of Orono �-' 2-'3 <br /> Building Permit Application for Maintenance 1 Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> "� l '�. Mailing Address: ��3�-�(�C�� <br /> %� ��^! � PO Box 66 Permit number: <br /> / � '�,� Crystal Bay, MN 55323-0066 Date received: 7—/ — <br /> I i Street Address: Received by: <br /> � <br /> S. �% 2750 Kelley Parkway Plan review fee: <br /> �� �/ Orono, MN 55356 � <br /> ��EtiHI)�`.� � C� <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 returr�ed. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 3 9 8 0 CHERRY AVENUE <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes X� No <br /> If yes, a special event permrt 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 atlowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: PROPERTY OWNER IS PERFORMING THE WORK <br /> State License# N/A Expiration Date: <br /> Lead Certification Number: N/A Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / omeowne (Clrcle One) <br /> Emaif and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: KEVIN SHULTZ <br /> Phone (day): 612-710-7 2 3 6 <br /> Address: 3 9 8 0 CHERRY AVENUE City: ORONO ZIP: 5 5 3 6 4 <br /> Email and/or Fax: KEVINRSHULTZC�GMAIL.COM <br /> PROJECT INFORMATION: Overall ro�ect descri tion: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑Fire Damage MCWD review 8 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) partial bsmt fin www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ $1, 0 0 0 . 0 0 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to provide alt 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 altemative 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 an ual update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the info on, lic � n not be issued. <br /> ApplicanYs Signature: Date: �� �� l;3 <br /> , <br /> Owner's Signature: � ------ " -_ .____ Date: � �� "I-� <br /> : <br /> Last Updated:03/06/2013 <br />