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CITY OF ORONO * z 0 1 z - 0 1 0 3 0 *
2750 KELLEY PARKWAY DATE ISSUED: 10/15/2012
ORONO, MN 55356-
(952) 249-4600 FAX: (952) 249-4616
ADDRESS : 980 COX FARM RD
PIN : 27-118-23-33-0012
LECAL DESC : SHADOWOOD FARM
: LOT 009 BLOCK 001
PERMIT TYPE : MINOR ALTERATIONS
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : W[NDOWS
ACTNITY : O/S BUILDING -UNDEFINED
VALUATION : $ 12,629.00
NOTL': WINDOW REPLACEMENT
APNLICANT PERMIT FEE SCHEDULE 236.00
SCHERER BROS LUMBER STATE SURCHARGE(VALUATION) 6.31
10751 EXCELSIOR BLVD
HOPKINS, MN 55343 MAIL-IN FEE 2.00
(952)277-1600 TOTAL 244.31
Minnesota State License#: BC239369 PA[D WITH CC# 3989
OWNER
WILLSON, CHRIS& SARAH
980 COX FARM RD
LONG LAKE, MN 55356
AGREEMENT AND SWORN STATEMENT
The work for which this pennit is issued shall be performed according to
the approved plans and specifications,applicable City approvals,and the
State Building Code. This pennit is for only the work described and does
not grant permission Yor additional or related work which requires separate
permits. All provisions of laws and ordinances governing this type of work
shall be compied with whether or not specified herein.This permit will
expire and become null and void if construction authorized is not
commenced within 180 days of the date of issuance,or if construction is
suspended for a period of 180 days at any time atter work has commenced.
The applicant is responsible for assuring all required inspections are
requested in conformance with the State Building Code.This permit may be
revoked at a � ie for due c e.
/v� /S�/Z
Applica t Permitee Signatu�� Date ��� �`'� � �
Issu By Signature Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
� Oc+:.12, 2012 9: 39AM No, 9702 P, 1
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I City of Orono
i Building Permit Application for Maintenance / Renovation
� (windows, doors, siding, re-roof, etc.)
� Mailing Address: Permit number, 07+���' Q�' L�
O�O�O Crystal Bay,MN 55323-Do66 Date received: ✓0�2���'
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I a ,, Street Add/ess: Reoelved by:
3�, G�' 2750 Kelle Parkwa '
�R��o�,�+ Orono,MN 55356
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Main_ 952-249�{600 Fax: 952-248-4616 www.ci.orono m� ' '
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> This application form must be completed in full and all required information must be submitted.
Incomplete applicatlons wlll be retumed. (Please print)
GENERAL INFORMATION: C^, p 0 � e � � �2 ,� 2 �
Job Slte Address: / Q ��-
Nfill this be a Parade of Homes�Remodelers Showcase Nome or other Display Home7 Yes o
N yea,a special event permit is required with Police Deparfinent and City Council approvel 60 days pric�to the event. Shuttle bus se►vice will0e
, required unlesa epplicant demonstrstes su(ficient on-slte parfong is available. Non-permitted events will not be allowed
CONTRACTOR/APPLICANT INFORMATION:
Name: -s'c�h e,rz-��. Q R�,.P:
State License# �C ,� 3 S 3 b q Expiration Date: 3 �
Lead Certification Number: y�l�}-r_ � �3 "S- � Expiration Date: �j!f���� a,�
(fvr work on omea that were constructed pNor to�976
� Phone: (office) (cell)
Mailing Addres : o City: ZIP;
Contact Person: (� c.�� Applicant is ontra o / Homeowner �c�tiie �a�
Email and/or Fex: � �- � -a ��I � q d
PROPERTY OWNER INFORMATION• I `
� Name: . �� fZa� ���ti� � W� �f S o „
Phone(day): � � • 3�Z— 5�.,
Address: _� � � � � � c�,.1�,�, � � �� City: L a-.� ca--O.n ZIP: .5.� 3's�
Email and/or Fax �
� � PROJECT INFORMATION:
rype of Projecr Any eorth movement may roquire
❑Door(s) ❑Remodel ❑Fire Damage MCWD review 8�permfls:
Minnehaha C�eek Watershed Distnct(MCWD)
❑ Re-roof, �sphalt ❑ Repair ❑Storm Damage 1B202 Minnetonka Blvd
❑Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven,MN 55391
Phone; 952-d71-o590
❑Re-roof,other(spec�iy� ❑Siding ❑�ther: (specify) Fax: 952�71-0682
wvwo.minne hahacreek.orn
[�1lfindow(s)
Ovefall Project Descllptlon: ��
�stimated Constructlon Valuation of P�oJect(excluding land) 3 j a (aa 5. � �
APPLICANT ACKNOWLEDGEMENT:
. Agrees to provide all information required or requested by the Building Department;
� . Certifies that the information supplied is true and oorrect to the best of his/her knowledge. The applicant recognizes that they
are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative
but to reject it until it is complete;
• Some or a►I of the infortnation that you are asked to provide on this application is classi6ed by State law as either private o�
confidential. Private data is information which generally cannot be given to the publ;c but can be given to the subject of the
data. Confidentiaf data is information which generally cannot be given to either the public or the subject of the data. Our
purpose and intended use of this information is to annually update our records and records of other govemmental agencies
re uired b lew. If ou refuse to su I the information the a lication ma not be issued.
� Applicsnt's Signature: �G�(� C�i--n. Date: �d '��. -'( ���_
� __..,_,a_,. ..............