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(JAN-2:-2017 11:42 FROM:TREBILFOUNDATION SYS 3205938720 TO: 19522494616 P.2'3 <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> �� Mailing Address- Permit number: (fid / 7 /-a.)7 <br /> (/c�� PO Box 66 <br /> Crystal Bay, MN 553230066 Date received: ( acs - /7 <br /> ' ,' Street Address: Received by: ---(1 -./ <br /> .i."41 2750 Kelley Parkway Plan review fee: (1 ir,�tA,� d <br /> ,tlQ� Orono, MN 55356 <br /> Total Fee: /5 by -7 <br /> _ Main: 952-249.4600 Fax: 952-249-4616 www,ci.orono,mn,us <br /> This application form must be completed in lull and all required information must be submitted. <br /> Incomplete applications will be returned. (Please pant) <br /> GENERAL JNFORMATIO T� <br /> Job Site Address: r3o (010-716 O <br /> Will this be a Parade of HHHomes, Remodelers Showcase Home or other Display Home? TYes 7 No <br /> If yes,a special event permit Is required with Police Department and Clty 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 I APPLICANT INFORMATION: <br /> Name: . , # ./ N iz4'J2t� e9 f2/4 - - <br /> State License# „� Expiration Date: •---5f'"~/dy <br /> Lead Certification Number: AM-77041 1::2- - .,' Expiration Date: L/_�?rZ i <br /> (for work on homes that were constructed•nor to 1978 7 <br /> Phone: illife (office) (cell) <br /> Mailing Address: {s `{�/ t .1, �� if,�� ' ZIP: S <br /> Contact Person: IFI , Applicant is: ontractor / Homeowner (circle one) <br /> Email and/or Fax: n , (- Scl /7_)aiy rgi. • . CQYrl r . - 7 � <br /> PROPERTY OWNER INFORMATION: <br /> Name: i MA s 1 s' ,E-seax- <br /> Phone(day): ,/2-, 4. + O �-T <br /> Address: /,.c ...,..126- <br /> . - It.d.J _w__ City: ZIP: �: 7 <br /> Email and/or Fax _..._ " <br /> PROJECT INFORMATION: _ <br /> Type of Project: Any earth movement may require <br /> 0 Door(s) El Remodel cl Fire Damage MGwl review 8 permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt poir 0 Storm Damage 18202 Minnetonka Blvd <br /> O Re-roof, cedar 0 Restoration ❑Water Damage Deepnaven, MN 55391 <br /> Phone: 952-471.0590 <br /> ❑ Re-roof, other(specify) ❑ Siding 0 Other: (specify) Fax: 952-471-0682 <br /> 0 Wlndow(s) www.minnehahacreek,oro <br /> Overall Project Description: aw <br /> Estimated Construction Valuation of Project(excluding land) $ 3 (tea <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 <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no oltemative <br /> but to 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 <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> required by law_ If you refuse to Supply the information,the application may not be issued. <br /> Applicant's Signature: (j?, kL 'z..e._',,.. !.{.{ /� Date: /"--?0—/-7 <br /> Last Updated 0S-08-2011 <br />