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• JUN-29-2013 08:22 FROM:TREBILFOUNDATION SYS 3205938720 T0:19522494616 P.2�3 <br /> . , • 7".l".� <br /> City of Qrono <br /> Building P�rmit Application for Maintenance ! Rertov�tipn <br /> (windows, doors, sidin�, re�roof, etc.) <br /> �p� Mefll O �: Pennit number: �l 3-� 'rj g <br /> O � ��ey,MN 65373-�66 f�ate recel�ed' '1 — l —�3 <br /> St�et Address: ��d�' <br /> �, � 275Q Kelley PBrkw�y Plan review fee: <br /> o� drono.MN 55356 /� <br /> Tofal Fgp' ��. t • V v <br /> Main_ 952-2a9-460� Fax: 952-249�46t6 www.ci.orono.mn.us <br /> Tt�is application form must be completed in full and all required irtformation must be submitted. <br /> Incomqlsk�appUcations wlll be returned. (Please print) ��.�/��i <br /> GEN�RAL INFORMATI�N; <br /> Job SlteAddr�s: _.).3�$ 1�e� p{'Za�'h _ear�l� _ <br /> WIII thls ba s Parade of Flomes,Remodelers Shawcaae Flome or other Display Nome'T Yes No <br /> Kyes,a apedet ev�ent pemJt Is,aqulred w�1r Aelke Dspertment and CJty Coca�app�owH 4G dsra p►br b da e�r►►t. Shutfle bu�s ssnrrcce w1H bs <br /> requl,a�d u+Msss oppucanr dtrmonsbaha s�rrc on�s1�parx/np!s ava�a�e. Mon�pem,aroa svs,us wra na os arbHeo. <br /> CONTRACTOR!APPI.ICAN7INFORIiAATIQN: <br /> NBme: �.�.��."T� h' 1 �o�S�4'�+.Bt]�.1a�3--�.,.t� <br /> smta�.�cense� �c.y,��,� �� � ���at+on oa�e: �31- �y <br /> ,� <br /> I�ead Cerafi�ation Number, N A�'- �n�,,a�c�.. � ^ Expiration Date: r�- �f�- f�R <br /> (for wark a�hanea�t wero Con�iructed prlor t�o 1878 <br /> PhOne: - - � (offce) (ceq) <br /> Mailing Addre9s: � City: �,q�IP: <br /> Cohtact�erson: �����p,Q, �,�,,,��� ApPlicant is: nt�actor 1 Womeowner (ara.a�r1 <br /> Email and/or Fax; . c� � <br /> PROP�R7Y 01NNER INFQRMATION: <br /> Name: � " <br /> Phone(day): !21 s'�- ��`���3 9 <br /> Address: 13.!�}$ �,'�,,,'i" �'o��,i� L�.i r�l� C�ty' RCf4f)Q7.1S1� zIP: ��.�L�;l <br /> Email and/or Fau �Qn��.,�, a � �,mas 1, c.r.nn <br /> PROJEC7 iNFORMATION: <br /> Type of Any eard+rriovement may requln <br /> G7��(b) C7 Remodel C)Fire oamsge MCWD revlew�permlb; <br /> � Mlnnehena Creek wacershed[HsaicE(MCwD) <br /> Q Re-roof, 1t �apair Q Stom�pamage 18202 Minnatonk�Blvd <br /> Q Re-roof,rxdar Q R�tqrdtiqn ❑Water Damage �ve^,MN 55391 <br /> Pttone: 952�71-05�0 <br /> ❑Re�roof,oq�sr Upeeih) �SidlnO CI Od�rer:(apec�fy) Fex: 952.a71.0882 <br /> C�V��dc�w(sy www. inn h <br /> Overall ProjeCt posc�i ion• ` <br /> �st�mated ConstrucHon Valuatlon of p ect ex�ludfn tand) ' S p <br /> APPLICANT ACKNOWLEDG�MENT: <br /> � Agrees to Arovide all inf�xmaGon required or requested by the Buildiny Clepartmer�t; <br /> • Certieea that the ir�ormatlon suppliea is true and oon�scx to tne best of his►her Ia�orMedge. The appliqM revdg�izas that they <br /> are aoley rUsponsible for aubmiE�ng�complete appliCadon belr�g aMraro that uppn failure tp qp sp,the staff has no alt�matfva <br /> but tq rejsd�urttll R Is oomp��te; <br /> • Some or all of the infortnatbn that you are asked t0 provide on�tis applfcabon is dessified by State 18w as either privato or <br /> oonlidenpet. Privete data ia inforrna6on whidt genar�lly cannod bo piven to the public but can be given to tt�e subject of the <br /> datg. Conftdentfal date is iniormation wh;ch yeneralty CgrinOt b9 given to dithor tho publiC or the subJeCt Of the de�. Our <br /> purpase and iritondod usa of this infoimedan is to ennually upd� our reoords and reoorda ot oUter gov�emmental aqencies <br /> uired 1pw. If ou refuse to su 'the inf�nrmeti the a icatlom m �pt pe.i8sued. <br /> A►PplicanCs Signature: 6 . Date: � �� <br /> laet upaetad: 08�09��2ot1 <br />