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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> D <br /> ��0 ` Mailing Address: Permit number: ACYY-OD/ <br /> 1� PO Box 66 <br /> 0 Crystal Bay, MN 55323-0066 Date received: 0?-032)--)g <br /> Street Address: Received by: 12, 9 F <br /> et, ` 2750 Kelley Parkwa 1I� p� ( CI Plan review fee: <br /> tqk �� Orono, MN 55356 (jUl .( <br /> ESHO Total Fee: 0 gJqo , :J <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: /vl, t /o.i.�s L�.v�z <br /> Will this be a Parade of Homes, Remodelers Showcase Homeor other Display Home? El Yes 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 I APPLICANT INFORMATION: <br /> Name: €I 1.4-y ‘2- <br /> State <br /> State License# t'��r�� Expiration Date: � /•-/1" <br /> Lead Certification Number: MAT-F-15-01-7-i Expiration Date: 3-2o-Z© <br /> (for work on homes that were constructed prior tb 1978" <br /> Phone: (cell) 6, /2 3 ec,- //(oS- (office) S .'-. <br /> Mailing Address: et/,o St. kS v ,`„� City: 44,n1,.. 410 A L._ ZIP: S5-3 6,3- <br /> Contact Person: e.`l-f Tohkisar _ Applicant is: ontrac9D / Homeowner (Circle One) <br /> Email and/or Fax: s�.c,fi f add,htr Licvi.«S,La,►-` <br /> PROPERTY OWNER INFORMATION: <br /> Name: c✓' 49( r-t� LLC <br /> Phone (day): l Z- ?'7 s7 ?72 <br /> Address: L/yt! SSf. City:Cf6e fsic„_ ZIP:.S3.33/ <br /> Email and/or Fax: c.Ole rr~i qc.v‘O Vc.vc4f— 'r J.C- <br /> PROJECT INFORMATION: Overall project description: 1111e"-ic <br /> Type of Project: Any earth movement may also require <br /> ❑ <br /> Door(s) 3 Remade) 0 Fire Damage <br /> MCWD review&permits: <br /> ❑Re-roof, asphalt ❑Repair 0 Storm Damage Minnehaha Creek Watershed D'i'strict(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof, cedar 0 Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> XWindow(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ gD,c)OD <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all infdrrnation reqU)red 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 anntfatiy update our recordsand records of other gaverhrnentaf agencies required by law. If <br /> you refuse to supply the informatio he application may not be issued. <br /> Applicant's Signature: Date: e2-2-2 <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />