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10/01/2014 15:03 6514303706 CRAFTSMEN HOME IMPV PAGE 02/02 <br /> o <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement I Renovation <br /> (No structural (expansion. only windows, doors, siding, re-roof, etc. <br /> Mailing Addmss: Permit number. / vZ <br /> PO Box 66 <br /> Crystal Say,MN 553234MOO Date received: /0 — <br /> SheetAddress: Deceived by: <br /> 2750 Kelley Parkway Plan review fee. <br /> Fl Orono,MN 55358 C;2-17300' <br /> />�� <br /> ES H O'Q"� Total Fee: C <br /> Main; 9$2-249-4600 Fax: 952.-2494-616 www.u.orrono_mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned, (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: „2 l? A)0?71-194,7--C 2.2 _ <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? L1 Yes Ono <br /> 9 yes,a Vedef event penny!s required w9h Pakim Deperhnent one City Coundl approval W deli's p0rto the event Shum flue se►vfce will be <br /> r�quirmsd unless appllcsnt demonstraias ear�rdent tlri,4J7e parking fs available. <br /> Non pemuHred events wl8 not 6s a8awW <br /> CONTRACTOR l APPLICANT INFORMATION: <br /> Name: <br /> State License# p Expiration Date: 3—3 <br /> Lead Certification Number IV ff $ 4- I Expiration Date: -4Zg w <br /> (for work on homes mat were construcW prior to 1998 <br /> Phone: (Cell) <br /> Mailing Address: '7 +SS- E-9 4l�' City: ' r Pr ZIP: <br /> Contact Person r Applicant is: Contractor I Homeowner (amts om ) <br /> Email and/or Fax: _/_,5f- X30 T70 /°1c-4 e Ck I- $dry/CQ.Goth <br /> PROPERTY OVMER INFORMATION.- <br /> Name- <br /> NFORMATION:Name: I p4 L��ddlJa� <br /> Phone(day): &.I-A.-..7'4.1- <br /> Address: 217ytw-rw G AT^ 90 <br /> Email and/or Fax: yl.r1 CA ri A 0! & c db^lk <br /> PROJECT INFORMATION; Overallo ect description._ <br /> Type of Project: Any earth movement may also requim <br /> [3 Door(s) [J Remodel ❑Fire Damage MCVVD review s permits: <br /> r]Re-roof,asphalt [3Repair E3 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ©Re-roof,cedar ❑Restoration ©Water Damage Deephaven,MN 55391 <br /> ❑Re-roof,other(specify) Siding IJ Other:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> 0 Window(s) +eww.minnehabacre-ek o� <br /> Estimated Construction Valuation of Project(excluding land) $ D <br /> APPLICANT ACKNOWLEDGEMENT: <br /> + Agrees to provide all inibimation required or requested by the Build"mg 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 irdormatlon is to annually update out records and reowds of other governmental agencies required by law. If <br /> u refuse to supRlyAv kf5Mffqn,the applMun may not be issued. <br /> Applicants Signature: Date. <br /> Owner's Signature: —_----_-__---_--. . .... _.__.. ._ . Date: <br /> i sst Updated:n3 SQ013 <br />