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To: City of Orono Page 2 of 4 2018-04-05 21:24:05(GMT) 15072999410 From: KRISTIN LOEFFLER <br /> , <br /> • <br /> City of Orono <br /> Building Permit Application for Maintenance J Replacement I Remodel Rei ' <br /> (i.e.windows, doors, siding, re-roof, etc.—NO STRUCTURAL EXPANSION) <br /> (7;,,sitniv <br /> Mailing Address: .CA:0 00 <br /> 0\ PO Box 6647 <br /> Crystal Bay,MN 55323-0066 4,„ bate r ifled c. <br /> I Street Address: RtCellVeCtlbit' 104/Lel to <br /> �\A 4fr �' 2750 Kelley Parkway 9/61/� len reviews , ° 0 <br /> \ t s, �G Orono,MN 55356 2 ,t <br /> H9a . Total• <br /> Pee { l.��/ c <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono,mn.us .. ';,.:, r. <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: Q 5-/ d,-lhw�c <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? 0 Yes ❑ No <br /> it 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 wAl not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: vMPlc te-, 5CLcc ..Lv%4 g y 5 litiin 5 <br /> State License# ii / 9i3171 Expiration Date: 3/3J AO <br /> Lead Certification Number: /1Jq-j .. /OSOj 2-A Expiration Date: 2/ IL j ?) <br /> (for work on homes that wen constructed prior to 1978 <br /> Phone: (cell) 507- Qq 5-- El-,A3 (office) 5.0 7 - 1 k 7-0SO, <br /> Mailing Address: c3 .�, i1 r. City: V 0 ZIP: 5.00 <br /> Contact Person: (.4.4_,,s Applicant is: Contractor I Homeowner (Circle One) <br /> Email and/or Fax: i's e „ i .. se A.._ r. C•oro i <br /> PROPERTY OWNS FOR TION: <br /> Name: ' it OCAS c- <br /> Add (day): — <br /> Address: city: Ord/)o ZIP:551,i 3 -GD'C <br /> 1-10�/ iii-,11 Ad.,. <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project descriptiont_C 1":W j 5 pa“,u- e,,r4-4 P5u IG ti-9,ft <br /> Type of Project: Any earth movement may also require <br /> ❑Door(s) El Remodel 0 Fire Damage PACWD review&permits: <br /> ❑ Re-roof,asphalt ®Repair ❑Storm Damage 16320 <br /> Creek Watershed District(MCWD) <br /> 16320 Minnetonka Blvd <br /> 0 Re-roof,cedar 0 Restoration 0 Water Damage Minnetonka,MN 55345 <br /> 1-0590 <br /> ❑Re-roof,other(specify) 0 Siding 0 Other:(specify) Phone: 952 <br /> Fax: 952-474-06621-0882 <br /> D Window(s) www.minnehahacreek,prq <br /> Estimated Construction Valuation of Project(excluding land) $ I I/7 5 <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 Oven 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 suppl the information,the application may riot be issued. !/ff _.. <br /> y/ <br /> Applicant's Signature: ��� Date: —!/ <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />