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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 /> Mailing Address: Permit number: 40` S �3#3� <br /> �o V <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066( p Date received: (3/24 h <br /> c\\N Street Address: <br /> t1r 2750 Kelley Parkway Received by: <br /> t i`� Plan review fee: i�p a , 5 �( <br /> C� <br /> l9KESHDR� Orono, MN 55356 aV� CD)p/S p03dN7 <br /> Total Fee: U_ <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) �5 7,U <br /> GENERAL INFORMATION: � <br /> Job Site Address: A 00 (3ederwc�ce C)ri _ , 0v-oetO, /MI 5 5 35(, <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: /Mat?t-z-old N-ome1 Kt' <br /> State License# 5G-,?.g 55 30 Expiration Date: 3_ at /Cf <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (0l0—a - (office) ei6a— 57- 3/3 <br /> Mailing Address: 5750 1-1-j VI►n,&v a5 City: VVt.a ZIP: 5 5360 <br /> Contact Person: -J - Nkat za[ Applicant is: ontracto]/ Homeowner (circle one) <br /> Email and/or Fax: Jimae+ L ✓ }tP �n�- h.P4- <br /> PROPERTY OWNER INFORMATION: <br /> Name: Al A.za d <br /> Phone (day): <br /> Address: ?oo Q}41-€.- City: O;—o - U ZIP: 5535(0 <br /> Email and/or Fax: a _ ��zcz d e r✓l Gh s j_co <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 CI Repair 111 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof, other(specify) ❑ Siding CIOther: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 30100 0,00 <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 information,the a••lication ma not be issued. <br /> 4 <br /> Applicant's Signature: - )I i ' 'I Date: 3--21 -18 ED <br /> MAR 21 2018 <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 CITY OF ORONO <br />