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City of Orono <br /> Bui,lding Permit Application for Maintenance / Replacement / Remodel <br /> (i.e, windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> O MailingAddress: Permitnumber: GG�s-OG ' <br /> � �O PO Box 66 <br /> Crystal Bay, MN 55323-0066 � Date received: � ZS 5 <br /> Street Address: V" / Received by: 2i� <br /> yF G� 2750 Kelley Parkway C�'� 1' �J Plan review fee: � �}r/'� <br /> Orono, MN 55356 ��'J <br /> `�'�fSH��� I V� �� <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 bmitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: / ��'� % ' ) �� � �'� I/L <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 s rvice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/A�PLICANT INFORMATION: <br /> Name: LLKK� �L'L (��L�25 zr'vL. <br /> State License# � ��� � 7� 7 Expiration Date: 3/ / ^ <br /> Lead Certification Number: ��T - ���j �'`j�� Expiration Date: �-/�3o�j� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �/�_ 3��_ j��� (office) j��- .���-,,7�a� <br /> MailingAddress: �-70 l�/CSl 7�t ST City: �`,��,�� ZIP: S-S'y�p <br /> Contact Person: �,�����-� ���j�_ ���-�— Applicant is: Contrac� / Homeowner �c��ae o�e> <br /> Email and/or Fax: -1c1ltZ���� �' (�le�kP���^�l, C�r-� <br /> PROPERTY OWNER INFORMATION: <br /> Name: _��� 1 j11L� Ci �LCN/�'ELL �N� L j�,�N� t� �/l1lfSSC-/v <br /> Phone (day): `(S�� �a�.3/5� <br /> Address: �RS p=KE�NC/� C����, '112-�-�%. City: C�,��/�b ZIP: �`�3��/ <br /> Email and/or Fax: j�����w/`�,� , C�vt� <br /> PROJECT INFORMATION: Overall project description: ��C�tNI�� �' �UGG'�I ��l-/l'"(�,E�- <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review& permits: <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ 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) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ `�[�OO,oL <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 /> ou refuse to su I the inform tion the a lication ma not be issued. <br /> `'�� % -// <br /> Applicant's Signature: � �' y Date: -3 <br /> Owner's Signature: Date: <br /> Last Updated:January 2015 <br />