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From: 04/25/2017 10:27 #245 P.002/002 <br /> 4 .. w <br /> 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 /> OMailing Address: Permit number:C:20)7 -1)-0 /o <br /> No PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: (ii-A v--17 <br /> Street Address: Received by: -— <br /> 2750 Kelley Parkway lliF <br /> ��. G:y Y Pian review e: <br /> Orono,MN 55356 <br /> lkES H00 <br /> Total Fee: Ssio 0. 07 <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: / � f <br /> Job Site Address: LO 2-5 cold Z-0 6_:4\ 1.-CJ<4- -go aJ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? 0 Yes Filo <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-peen tted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: //a�� • <br /> • <br /> Name: A l'Sir vi siy-Lv 0 P\CO 1M. '\eA ot, [ <br /> State License# C...-14 Expiration Date: 03 11$ <br /> Lead Certification Number: AT- 15 24 L--1 Expiration Date: b s1 1 2O <br /> (for work on homes that were constructed prior to 1978 ! l <br /> Phone: (cell) (p f 2.--Q(0G- ; 2,6 Z (office) -7 4,.. - 11-7q-2-7 0 0 <br /> Mailing Address: 51 �y � a4 S� # I 0 City: e p(a ih ZIP: 55ci' <br /> Contact Person: T:,r, " L0.Aer o Applicant is. ntra o / Homeowner (circle One) <br /> Email and/or Fax: bt,.0-eke-A Q t L ++clat•e--tb,,vN <br /> PROPERTY OWNER INFORMATION:y..� j('e _L ) <br /> Name: ,y`1 "�L11 �� l TirV 7 L-O!�� <br /> Phone(day): <br /> Address: ,y„v� pis Odo crJ;, City: ZIP: <br /> Email and/or Fax: <br /> II /�, t <br /> PROJECT INFORMATION: Overall project description: Qgltn t� 1 p�tV�,O‘.544 SCAq ,s t <br /> Type of Project: (( Anyjiarth movelnent may also require w <br /> JDoor(s) 0 Remodel 0 Fire Damage MCWD review&fes' eww6 <br /> ElRe-roof,asphalt 0 Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) , <br /> 15320 Minnetonka Blvd <br /> 0 Re-roof,cedar <br /> 0 Restoration 0 Water Damage Minnetonka,MN 55345 <br /> Re-roof,other(specify) (specify) <br /> Phone: 952-471-0590 <br /> ❑ Siding 0 Other.(s Fax: 952-471-0682 <br /> $f Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ SS) Ono. OD <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 informati.. is to annually .•ate our records .. records of other governmental agencies required by law. If <br /> you refuse to supply the inf• ati•. '*i'.,. ..- ,-. bed. <br /> Applicant's Signature ' <br /> lt. - � Date: 4/Z...C____Ii7 <br /> / <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />