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! � ' � City of Orono <br /> `Buiiding Permit Application for Maintenance / Replacement 1 Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> 4��� n��;,►g�w�: �� : _ -� <br /> PO Box 86 <br /> Cryst��BaY,MN 55323-0066 Daee reoeiv�ed: <br /> � �, Sh�et Address: . <br /> �. � 275014e11ey Parkwa <br /> �'�k SHoa,,�'G Orono,MN 55356 �(5"�b15 �review iee: �� <br /> Total Fes: <br /> Main: 952 249�4600 Fa�c 952-249-461g www.ci.orono.mn.us <br /> This applica�tion form must be c�mpleted in fult and all required infamation must be submitted. <br /> incomplete appltcations wiil be roturned. (Plesse priM) <br /> GENERAL INFORMATION: <br /> .Job site Address: 1590 LoN� LAKE BLVD ORorvo MN 55356 <br /> WIII this be a Parade of Homes, Remodelers Showcase Home or other D�play Home? Yes No <br /> lI prs.a spsclal e�t PsmNt�a�sq�rsd w�l►P�ollce Dsp�bnent and Cky Cound/a�wd 80 days pria b N�s svrnt Shums bus san�ice w�be <br /> raqukrsd w�Asss qpp1�dsnanab�s suAlatent o►►.sRe parldr�is ava�ebls. Non-psnn►[�ed e�sMa wip not es a�bwerl <br /> CONTRACTOR 1 APPLICANT INFORMATION: <br /> Name: �iLEN FLAHERTY <br /> State License# Expiration Date: <br /> L�d Certffication Number. Expiration Date: <br /> (1�or w�o�ilr on honws�Iwt w�a+s ao�atruci8d p�lor b 1978 <br /> Phone: (�n 6 51 -7 1 -5 6 9 (o�e) 612-�3 2 7-3�344 <br /> Mailing Addt+ess: _1 S 9 0 I n ti r A K F 8 v� C� nR n �n ZIP:S 5�S� <br /> Contact Person: G�E N F L A H F R T Y Applicant is: Contrador / Homeowner �x�on.� <br /> Emailand/orFa�c GLENJFLAHERTY�GMAIL coM Fax F1� R�7 �f1S1 <br /> PROPERTY OWNER INFORMATION: <br /> Name: GLEN FLAHERTY <br /> P��(�Y>� 651 -231 -5693 <br /> Address: 1590 LoNe LAKE BLVD City:ORONO Z�P:55356 <br /> Email a�d/or Fax: <br /> � aS or <br /> PROJECT INFORMATION: Ove�B 'eCt desCri ' : R E P L A C I N G F R 0 NT T I R S l � �� <br /> T�°��� Any earth m��y �i <br /> ❑Door(s) .."Remodel ❑Fre Damage MCWD rsvkMr�penmits: <br /> ❑Re-roof.asphalt ❑Repair ❑Storm Damage Minnehaha Creelc W�shed Disb�ic�(MCWD) <br /> 18202 Miru�etonka Bh�d <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Deepha�nen,MN 55391 <br /> ❑Re-roof,other(sP�KY) ❑Siding ❑Other. (spec�fy) Phone: 952�71-0590 <br /> ❑Windowts) Fax 952�71-0662 <br /> www.mi nehahaaeek.ora <br /> Estimated Constru�tion Valuation of Project(excluding land) ; 1��(l_(1� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • A�rees to provide all information required or requested by the Buiiding Departrnent; <br /> • Cerdfies that tl�e information supplied is true and�to tl�e best of hislher knowledge. The applic�rrt reoo9tdzes that they are <br /> solely r�esPonsible for aubmitting a oomPlete applic�ion be��9 aware that upon failure to do so,U�e�F has no alberr�ative bat to <br /> rejed it untii it is c�mPlebe; <br /> • Some or ali of the informafion that you are asked to provide on th� application is dassified by S'tate law as eitl�er private or <br /> confid�tial. Private data is infonnation which generaly cannot be given�o the public but can be given to the subje�of the dats. <br /> Confidential data is iMortnation which generalty cannot be given to either the public or tl�e subjed of the da�. p�,�r p�$pose and <br /> intended use of tltis iMortnapon is to annually update our reoords and revords of omer govemm�i agencies requir,ed by�ew, If <br /> ou retuse to s the i afion ic�tbm m �ot be issued. <br /> Appiicarrt's Signature: Date: ld �1 <br /> Owner's Signature: Date: � �� � <br /> Last Updarted:January <br />