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City of Orono <br /> ` Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> ��i V Mailing Address: Permit number: �L9/ £/_ /C> 7 <br /> O PO Box 66 �� <br /> Crystal Bay, MN 55323-0066 Date received: /11 5 —/ <br /> Street Address: Received by: 1. 0. <br /> y� c; 2750 Kelley Parkway Plan review fee: <br /> tilL. Orono, MN 55356 C/ <br /> �'�ESHO� / 7 5/ 7� <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 returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: /13c dco c� Shi'r_ & /2c <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ 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: 44/47 /2 5W2 /� rP7C. - <br /> State License# Bc_ 3 0 9d (r, Expiration Date: 3 204.5— <br /> Lead <br /> o/SLead Certification Number: /It+ Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) Col z -E),.s--0 - y OO - (office) <br /> Mailing Address: //4,/ urv9-ye-4j,9._ Av,0 .x[ 208 City: / x,444-- ZIP: S~S'3P/ <br /> Contact Person: -4 C4/11-.S CA) Applicant is: Contrac • / Homeowner (circle One) <br /> Email and/or Fax: met e_ w~e sive FA r,44,p,f-S . Goi,-.. <br /> PROPERTY OWNER INFORMATION: <br /> Name: g //iv() SEP 4' .Se h VV[L <br /> Phone (day): 6(2, - &' 9 -7/S9 <br /> Address: /9a/4 /-4f-e --4,-,-,c+,o F Qo,3k0 City: Co2rc�2,,/yl ZIP: 5-5-3`f <br /> Email and/or Fax: ESC4f aF(L @ Cfivh4e /NOy . co,-/--- <br /> PROJECT <br /> ortePROJECT 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 /> El Re-roof,cedar El Restoration ❑Water Damage Deephaven, MN 55391 <br /> CI �Re-roof, other(specify) , Siding 0Other: (specify) Phone: 952-471-0590 <br /> r Fax: 952-471-0682 <br /> 'Window(s) g/�g//� ir-/VFA/ www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ /$O,D-& <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 annually update our records and records of other governmental agencies required by law. If <br /> you refuse to supply the info atio he application may not be issued. <br /> Applicant's Signature: `-L Stu r-- Date: re .)"-/jam <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />