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City of Orono �d�; (�-- <br /> �;�ilding Permit Application for Maintenance / Replaceme t / Remodel <br />` (i.e. windows, doors, siding, re-roof, etc. N STRUCTURAL EXPANSION) <br /> �O� MailiPO Bo�r66� �I� Permit number: �C` �� � � OS <br /> � Crystal Bay, MN 5 23-0066 Date received: � � 1 1 ►S <br /> Street Address: �j�'� ���'���"--"—'"�"`-�----- <br /> y G� 2750 Kelley Parkway ���-r�/" - Plan review fee: � >� �-- � <br /> `� Orono, MN 55356 <br /> 1�xFSH��� '___ _--- .._ .. <br /> __.,.__.__.._�._.._ _._....____�.__.__ <br /> _.____ _.__.._� <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 returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �� Zl�'I 0141� <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 se ic will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: '�µ�' ��/�E �il� �I�Nl�?C7�/YIE� <br /> State License# �jc(o�j5�l�7 Expiration Date: 3 3f / <br /> Lead Certification Number: �/�}-r_���3p� -� � Expiration Date: � �� /7 <br /> (for work on homes that were consfructed prior to 1978 �� <br /> Phone: (cell) 9S� -80 _ (office) 9-s� -`�30 -c�'��% <br /> Mailing Address: � v,�/� � City: �,t/�t/�p��}- ZI P: SS3�.s <br /> Contact Person: �� �/'r.1C���f�N Applicant is: ontractor / Homeowner (CircleOne) <br /> Email and/or Fax: G�v�-����� �;yyj���. ����- <br /> PROPERTY OWNER INFORMATION: � / <br /> Name: L-l4N� ANt� f�"�L�7r l�//JE� <br /> Phone (day): �/7 _970 -/930 <br /> Address: 9 9tf ,/�c�`1' �h9 2C�0 City: a�Qp�� ZIP: 5'S 35!v <br /> Email and/or Fax: �{SL�//�/� �C Urr/piL <br /> PROJECT INFORMATION: Overall project description: <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) /=1/��5�-{GOc�€R(,EvEI� www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project (excluding land) $ faD,ODU <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 in o a ' . the a lication ma not be issued. <br /> Applicant's Signature: Date: � � /S <br /> Owner's Signature: Date: ��J�� <br /> Last Updated:January 2015 ' <br />