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Prom:PURPOSE DRIVEN FFax:(8i7)7254737 To: Fax: +1 (952j 249-4616 Page 2 of 4 07l2512014 1:33 <br /> . . . <br /> City of Orono <br /> Building Permit Application for Maintenance / Re ment 1 Renovation <br /> (No structural expansion. Only windows, doo sidin , e-roof, etc.) <br /> ,�O�TO Mailing Address: permit number. / �� <br /> �y PO Box 66 � <br /> Crystal Bay,MN 55323-0066 Data received: — <br /> Street Address: Re�wed by: <br /> � �' 2750 KelEe Parkwa <br /> ti�. G� Y Y Plan revlew fee: <br /> t �, prono,MN 55356 � <br /> '�kFs HO�` Total Fee; � /�j�l' �� <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 appllcatlons will be returnad. (Please p»n� <br /> GENERAL INFORMATION: � � ����Iv 1 <br /> Job Slte Address: � C1 <br /> Will this be a Parade of Homes,Remode ers Showcase Home or other Dlsplay Home? Yes No <br /> p yes,a special evenf perm�is requirad wrth Pofice Department end CJty Counal approve!60 days prior fo the event. Shutf/e bus service will be <br /> r�equlreC un(ess applrcant demonsbates suh7cfent on-site psrking is available. Non-permifted events wiU not be albwed. <br /> CONTRACTOR/APPLICANT INFOR A 10 � <br /> Name: '� ��Q„�jpy� <br /> State License# �� Expiration Date: ��31 ZatS <br /> Lead Certification Number: N�}'r 79(y� Expiration Date: �U ?0l5 <br /> (for work on homes fhai+vere »sbuc�d p�ior to 1978 <br /> Phone: (celq Z�y�j•�$ � (offce) 7G37(o"�-�1737 <br /> Mailing Address: �,�j � � City: ,�,� ZIP: �3� <br /> Contact Person: 1 ;,n Applicant is: ontractor / Homeowner (Grele One) <br /> Email and/or Fax: ; fM�.� � <br /> PRpPERTY OWNER INFORMIATION: <br /> Name: �� G�anWI�,{� <br /> Phone(day): �Z �-�7"IJ <br /> Address: _ ��(o Lo�r�[f � C�Y��COYtD ZIP: �J� <br /> Email and/or Fax: " <br /> _ ' ;���i4. <br /> PROJECT INFORMATION: Overall ro'ect descri tion: i►�� c�wt <br /> Type of Project: Any earth movement may also require <br /> ❑Door(s) ❑Remodel ❑Fire Damage <br /> MCWD review 8�perm(ts: <br /> ❑Re-roof,asphalt ❑Repair ❑Stortn Damage Minnehaha Creek Watershed DiaVict(MCWD) <br /> 18202 Minnetonka Bbd <br /> ❑ Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof,other�speci(y) Siding ❑Other.(specify) Fax: 952-471-0682 <br /> ❑Wirxlow(s) www.minnehahacreek.ora <br /> EstPmated Construction Valuation of Project(excluding landl 5 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> 0 Agrees to provide all informatian required or requested by the Building Departmenh, <br /> ❑ Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> salely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to <br /> reject it undl it is comp�te; <br /> ❑ Some or all of the information that you are asked to provide on thls application fs classified by State law as either pnvate or <br /> confidential. Private data is intormation which generally cannot be given to the public but can be given to the subjecf of the data. <br /> Confidential data is iniormation 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 gavemmental agencies required by law. If <br /> ou refuse to su t 'nforma' th lication ma not be issued. <br /> Applicant's Signature: Date: Z �J � <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />