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<br /> City of Orono
<br /> Building Permit Application for Mainte ance / Replacement/ Remodel - Residential ONLY
<br /> (i.e. windows, doors, siding, re4roof, etc. — NO STRUCTURAL EXPANSION)
<br /> O� Mailing Address: Permit number: p742/7— 7�/
<br /> � 0 PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: 7-7-SCO /7
<br /> Street Address: Received by:
<br /> 1.<0 11 .. 2750 Kelley Parkway Plan review fee
<br /> e A,L Orono, MN 55356
<br /> dKE //--
<br /> SHO�
<br /> Total Fee: /v2\!�• 37
<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: /de5 4.--a7 l'77-C-V-,lijel n ,,,e � Q✓ -�v� m-,--- SST 7/
<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: M. -7 f2 4' .'''‘ /--i--.6". �g---97. --, -.0:-----'7-47' GilGc/7.l7. - - /
<br /> State License# ���3/G y.0 Expiration Date: y ,
<br /> Lead Certification Number: ......270 7 , -2 Expiration Date: y )-9`
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) (2 ) ‘/6-- ic- o' (office) (563) 7., _,‘-4,„ ,
<br /> Mailing Address: /f 77/e, ,,"1-'7 ss City: ,e,y7„ 7/ ZIP: r:c /E
<br /> Contact Person: z,...,,,7- isC��t/�i f,✓ Applicant is: Cd-ontract Homeowner (Circle One)
<br /> Email and/or Fax: ,-4,44-x, v,e-� C2/�;,-.,,,,r, �o,.,,--2 ,.-,,2,-r , cam-`
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: 47 ,s' Tv��.„4 „..C--"Atr-- /a-
<br /> Phone(day): 6./7-- Ve/- a7 9 f
<br /> Address: yU Gas<.--aijraX, -e, , /ate City: ."/2c�4:7 ZIP: f3-79
<br /> Email and/or Fax:
<br /> PROJECT INFORMATION: Overall pro.ect description:
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) IDRemodel ❑ Fire Damage MCWD review&permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑ Re-roof,asphalt 0 Repair ElStorm Damage 15320 Minnetonka Blvd
<br /> 0 Re-roof,cedar 0 Restoration 0 Water Damage Minnetonka, MN 55345
<br /> El Re-roof,other(specify) IDSiding ❑Other: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> //( lindow(s) lit Zia psi -!^^r Tial 9o,.,.....-- 6 www.minnehahacreek.orq
<br /> Estimated Construction Valuation of Project(excluding land) $ SoU0
<br /> o.o
<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 ur records and records of other governmental agencies required by law. If
<br /> you refuse to supply the information,the application m y not be issued.
<br /> Applicant's Signature: /eel- ,, G%X - Date: 7/‘//-2
<br /> Owner's Signature: Date:
<br /> Last Updated:January 2016
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