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City of Orono a 3 7 <br /> Building Permit Application for Maintenance / Replacement enovation pub <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) 8 <br /> OAT Mailing Address: Permit number: C&/ <br /> O Cr Box 66 <br /> Cry � <br /> stal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: _ <br /> S 2750 Kelley Parkway Plan review fee: L <br /> 61 2750 <br /> G Orono, MN 55356 <br /> Total Fee: Z�/ <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. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: a 1r3 ti 01a Deo-h 94 . vJa r zu N hA u sfS 59 1 <br /> Will this be a Parade of Homes, Remodellers Showcase Home or other Display Home? ❑Yes 7 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 service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: 59%)hor S t iris . <br /> State License# a3$01 Expiration Date: 3/511/9 <br /> Lead Certification Number: N t7' -a y ff6R _ Expiration Date: May 3, a of f <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) 763-5-53 —o3SoZ <br /> Mailing Address: 471to ya vt City: o ins o t ZIP: -5-4 <br /> Contact Person: Ro 6 Dom yn e Y Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: Ter% Alicia c,d4e <br /> Phone (day): q5a—471 — 75r9 <br /> Address: 'RY35! A stock RD City: woxx to ZIP: a3R <br /> Email and/or Fax: <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 /> 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.ora <br /> Estimated Construction Valuation of Project(excluding land) $ <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 pnnually update our records and records of other governmental agencies required by law. If <br /> you refuse to supply the inf rmation he application may not be issued. q <br /> Applicant's Signature: Date: 11� <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />