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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 /> T Mailing Address: ` <br /> ".0�VO PO Box ss RECEIVED Permit number: ��/�-pf/ of <br /> Crystal Bay, MN 55323-0066 Date received: r�Aon//p <br /> w� Street Address: AUG ZO�6 Received by: mT <br /> yF G� 2750 Kelley Parkway Plan revie fee: <br /> �l'�ES H 00' <br /> Orono, MN 55356 CITY OF ORONO Q <br /> Total Fee: 'i?ci1 7 . <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: n <br /> Job Site Address: S'Q ac, rcy s'I(� I eI nv(&u`ii, - <br /> Will this be a Parade of Homes, Remodelers ShowcaseMome or other Display Home? E 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/APPLICANT INFORMATION: <br /> Name: <br /> t eicl ro.y, Cleo.nii .1- Canc"irvci-ro,-1 <br /> State License# QCo0/0 .7 Expiration Date: I/3/752o/7 <br /> Lead Certification Number: 4/,4T - c2/ 7aa_A Expiration Date: 9/02A/.20020 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) 763 -623? - 21.33 (office) 763-SyY-2"76/ <br /> Mailing Address: 9da/ /c7" huenke /1J0/-7k City: „o/ ,,,o,-tl, ZIP: .s-S- 44/ <br /> Contact Person: Grv�/,,, Applicant is: (--n5ii Homeowner (circle One) <br /> Email and/or Fax: .r -FI re e^erwiir .. co/h 763 SS/ sr- a966 6r, <br /> PROPERTY OWNER INFORMATION: <br /> Name: q✓ely d- 6eoe?.e 1"un'K Ko€o she3 e <br /> Phone (day): 93-a-4 7 S- 3s9y <br /> Address: SyO o/d c.74--4/(17. .ea....e CitYLsyrf L. 1,,_ ZIP: .PS-..?...r45 <br /> Email and/or Fax: <br /> ilea G Pc.,eu Gee 7,.....11 . cer" <br /> PROJECT INFORMATION:\: Overall project description: /✓aTe,. - `„41,,, /” Sco •e <br /> Type of Project: An, <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage permits:MCWD <br /> ❑ Re-roof, asphalt 0 Repair 0 Storm Damage Minneh: _ Creek Watershed District(MCWD) <br /> 15320❑ Re-roof, cedar I ' <br /> j��testoration E Water DamageMinnetonka, <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) one ' <br /> Fax: 952-471-0682 <br /> ❑Window(s) <br /> Estimated Construction Valuation of Project(excluding land) $ •� d - ‘ - <br /> APPLICANT ACKNOWLEDGEMENT: .3./O l•. 0 7 <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 annually update our records and records of other governmental agencies required by law. If <br /> you refuse to supply the information,the application may not be issued. <br /> Applicant's Signature: "' Date: i -• a- r (c . <br /> Owner's Signature: � ,� .j Date: <br /> Last Updated:January 2016 .) / <br />