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09-21 -13:03:02AM;From:kuhl To 9522494616 9522588300 # 2/ 2 <br /> � ` '' ���City of Orono <br /> Building Permit Applica#ion far Main�enance/ Replacement/ Renorration <br /> (No structura[ expansion, anly windows, doors, sid�ngy re-roof, etc.) <br /> Mailing A�dress: PermR numher. � -�7 Cf� <br /> �d�� �� PO BOx 66 <br /> Crystal Bay,MN 55323-0066 Date received: �' <br /> Streef Adldress: Received by: <br /> � '' 2750�IKelley ParkW�y Plan review fee: <br /> `��,� , ��� �I Oron�o, MN 55356 <br /> 4rs�.�o� Total Fee: (g'3 ��� <br /> Main: 952I249-4fi00 Fax: 952'r249-4616 www.ci.orono.mn.ias <br /> This application form must be completed in full and all requfred information muSt be submftted. <br /> Incomplate a�pplfcatfons wlll be retur�ed. (Please print) <br /> GENERAL INFORMATION: <br /> Jab Slte Address: � G � <br /> Wlq thls be a Parade of Womes, Remodeler,s Showcase Home or other Dlsplay Home? Yes No <br /> !f yas,a spec�a/avanr p'ermlt is requi�ed with Pollce Dep�nment and City Councri�pprova!5a deys prior to the event. Shunle bus service will be <br /> requlred un'less appllcant demonstrates sufllclant on-site parking!s avallable. Non-permined events will not be allo�ved. <br /> CONTRACTOF�/APP�LICANT INFORMA71aN: <br /> Name� � l� <br /> State License# p{����-��d�=( I _ Expiration Date, 3/3� /t� <br /> Lead Certiflcatipn Nurnber: I Expiration Date: <br /> (for►nrork on homes that were consfructed prlor rp 1978 <br /> Phone: (cell) (office) � � • � <br /> Mailing Address: i. ' —' ` !; Ci4y: ZIP: <br /> Contact Person: '� ppliCant iS; ontractor Homeowner (C�rcle One) <br /> Email and/or Fax: � '' � <br /> PROPERTY OWNER'IINFQRMATION: <br /> Name: -t'p�? � �r��-�2�C;�� Aas�-t��,I� <br /> Phone(day): I <br /> Address: ' City: ZIP: <br /> �mai!and/or Fax: <br /> PROJECT INFORMATION: Ovecall ro'ect descri tion: <br /> Type of Projett. ' Any earth movement may also requlce <br /> ❑ Door(s) ❑Remodel ❑Fire Damage MCWD revlew&permlts: <br /> ' - : Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt I ❑Repa�r ❑Storm Damage �g202 Minnetonka Blvd <br /> �.Re-roof,ceda� I �Restoration , ❑Wat6r O�m�ge Deephaven,MN 55391 <br /> ❑Re-ropf,other(apeciry) ❑Siding ' ❑OtheC:(Specify) Phone: 952-471-0590 <br /> Fax: 952-471-OBB2 <br /> ❑Window(s) ;niww_minnehahacreP.k.nrq <br /> Estimated Construc#oon Valuation of Project(excluding land) $ � � <br /> APPLICAwT ACKNIOWLEDGEM�NT: ; <br /> • Agrees to provide al1 information required o i'requested by the Building Department; <br /> • Certifies that the I�iormation supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsibf for submitting d Comptete application being aware that upon failurA to d0 50, ihe staff has no altarnativg but to <br /> rejeCt R until it is aomplete; <br /> • Some or s;ll of thle information that you are asked to provide on thls application is classified by State 1aw as either private or <br /> confidentidL Pr � ta is info�rnatlon which generally cannot be given to the publiC but Can bg given to the subjeCt Of th0 datd. <br /> Confidenti ata!is infor tion whiCh g0neraAy cannot given to either the public or the 5ubjeCt of the data. �ur purpose and <br /> intended se of this iniormat n to nnually pda e records and records ot other governmental agencies required by law. If <br /> ou retu e to su I the infor io i ti n be issued, <br /> Applicant's Si nature: �'� f� Date: `�'ZG• /3 <br /> i <br /> i <br />