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- �'�r� 9 �.�- <br /> ��ty of Orono <br /> • B��ding Permit Application for Maintenance / Replacement / Renovation <br /> {No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> ���A���• Permit number: o?O/ - <br /> �D�O PO Box 66 ,/ <br /> Crystai Bay, MN 55323-0066 Date received: �"�rO'/7 <br /> Str+eet Address: �� Received by: � � <br /> s G� 2750 Kelley Parkway �- � Plan review fee: 9� <br /> `� Orono,MN 55356 <br /> ��kFSHO�� �o /S/- DaDS� <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 retumed. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 3 oq a I�I or�N�. S1�eve 1'�r i vt <br /> �II this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> !f yes,a special ewent peimit is requi►ed with Aolioe Deparbnent and City Couna/approval 60 days prior to the event ShutNe 6us servioe wiN be <br /> required unless appt�anf demonstrates suffcient on-site parking is availaWe. Mo�ermithed ev�ents will not be a/bwed <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �w�b,lia (z- Cc1HS�rk��i��rlc.. <br /> State License# �,G .3 9��t�o Expiration Date: 3,a�, �,a � <br /> Lead Certiflcation Number: F�cpiration Date: <br /> (for work on homes that were constructed prior t�n 1978 <br /> Phone: (cell) q 52,. 2,q Z..3-t �-� (office) 9 SZ�t O�O. I 3 5 2- <br /> Mailing Address: 3q Tv�ctte���,k�..� Ci : ��-���a, ZIP: $ S;$ <br /> Contact Person: -roa,d (��e�w2►Stci Applicant is: ntracto / Homeowner �ci.aea,e� <br /> Email and/or Fax: -},e��Q�,,,�p�\;a q,c��,,� ' 95 2-9�l�•l 3'1 J <br /> �'�ROPERTY OWNER INFORMATION: <br /> ��ame: ���i�l �' Wl c 1 V K h <br /> Phone(day): <br /> Address: �O�t� N��1�n Skore tJr. ���v� INa�2a-I�, Z�P� 5535 I <br /> Email and/or Fax: paK�dc,�N��q�yNH .t�1�/1 <br /> PROJECT INFORMATION: Overall ro'ect descri tion: <br /> Type of Project: My earth movement may also require <br /> ❑ Door(s) L�7 Remodel ❑Fir�e Damage MCWD review 8 permits: <br /> ❑R�roof,asphalt ❑Repair ❑Storm Damage ��nnehaha Creek Watershed Distrid(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 <br /> ❑Re-roof,other(specity) ❑Siding ❑pther:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ l 0 2. 0 o D •o v <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all infortnation required or requested by the Building Department; <br /> . Certifies that the infoRnation supplied is true and correct to the best of his/her knovuledge. The applicant recognizes that they are <br /> solely responsib�e for submittirg a complete application being aware that upon failure to do so,the staff has no aftemative but to <br /> reject ft until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is Gassifi�d 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 /> Confidentlal data is information which generally qnnot 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 reoords and records of other govemmental agencies required by law. If <br /> ou refuse to su I the info th a ication ma not be issued. <br /> ApplicanYs Signature: .� Date: �• �� • 1'1 <br /> Owner's signature: �` Date: I — �6' �� <br /> l.ast Updated:03I06/2013 <br />