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<br /> • C�ty of Orono �
<br /> Bui�ding Perrnit Applica��on for Maint�nanc� / Replacement/ Renova#ion
<br /> (No_structural exp�nsion. Only windows, doors, �iding, re-roof, etc,)
<br /> �r d/ -�lJ%/7
<br /> Maiffig Aci�►r�ss` �
<br /> ' �-Oj VQ PO Box 86 (�mit nUt�►ber
<br /> _ Cryst�l BeY,MN 55323-0066 �1`� pate rec�iv�ci:, /O - —!
<br /> � �reetAddresS: p\� �teceivec!by. : .
<br /> 5��, , G`'�' 27$0 Keltey Parkwey � PI�i�reView fee. ._�
<br /> t�tk�,�xb4�' Orono,MN 5535f3 l'/�f-- �!/.
<br /> Totall F�e:
<br /> _M�in: 952-248=46Qp Fax; 952�249-4816 www:d:orono.rttn.us '.
<br /> '�his applic��pn f4Fm musf be cofnpieted in full and ali rAquired informapon must bs submitted.
<br /> Incample�e appllcations wlli be return�d. {P/ease prirrt)
<br /> GENERAL INFOROfIATION; .
<br /> Jep�ite Address: �O�� S V �� �e a :
<br /> 1Nilt this be a Parade o.f Homes,Rernodele�s ShowC e H�me ot oti}er,W$play Mome? Y'es ;�No
<br /> r rres,a s p e c r a►e v e r�ner►,►�rs re�i►a a w�u►i�oo n eaarm,ern er,d crry cormdr epp,ova�eo aars n,lorm rhe ewer�t. strut�iee bus se„r�e w�i�e
<br /> Ieyulred uNeSs aPPNCenf alamoRsNates sul�cient on slte paKdnq la avaUabl9. Nan-petin�event's Wlll AOt tie 8doweal �
<br /> Name; � ��T�NFQRMATION:
<br /> ONTRACTOR 1 APPLI �!� , _ �: :, . - WC-.. . . , . . _
<br /> State License# ,���121 I�� Expiration Date: `3 ZD S
<br /> l.ead Gertificatio�l Number. .�.SR`t' 1 c��9'�--�. _ ExPiration Date` p , ? ZCrs r - -
<br /> (for work tu►homes th�t wet�e construct�ed prlor fo 19T8 �
<br /> Phone: (cel� 9'.5��9+D�36 .�6_ (dfflce? ���, .--��� ,�B�Id
<br /> M�tling Address; D: 2 � �,I D:; E Mc�:i Ci�Y ZIP: ��p�
<br /> _ . , •.
<br /> Gonfact Person: ,:,: ,v� G . Applicant is: tractor 1 omeouvner 1c�.ona�
<br /> - _
<br /> Email and/ar FaX: , n y b h�i��l~ett i�o...itle'ti
<br /> pROP�RTY C3WN�R iNF4RMATiON:
<br /> � Name: S'�`�J� �i'Ov�a►.
<br /> Phane(day)'
<br /> ,l�J �S :'�,�-- c� _ _
<br /> Aad►�s; ; � ,�,� � ��+;O _ zrP:s.3- j-Q�a
<br /> �mail andlor Fax: � �.. �IKl�1Q 1 ic�r,�
<br /> __
<br /> PROJE�T INFORMAT�ON: QVeratl ' ct desrxi tion: �i IiP.w�cao� .1' ��i�rt :���dot�:i c�kbj•
<br /> TYPQ of Project: A y�rth movemer�t may also r�uire .
<br /> []Dopr(S) �.ftembtlel [7 Fire Damage 1ACYYD reWo+�i.&!'�r+hits;
<br /> Minnehaha Creelc 1Nate[shed Distrid MCWD
<br /> C�Re-Yoof,asphalt ❑Repafr O Storm namage � �
<br /> 18202 FAinn�tor�sa SIYd.
<br /> �Re-roof,ced�r [j Restoration
<br /> tor (�We�er Damage Deephav�n,.MN 6539'I
<br /> ❑Re-ropf,other(�Pecih) 0 Siding [�Other:(spec�i�r} �'hohe: �52-471-0590
<br /> Fax: 9$2�71-dQ9Z
<br /> �ili�ndaw{s) _ y� innehahacreek:o�9
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<br /> Estimated Constnrotion Veluation of Projec!(excluding land) � �a p c?C?
<br /> APPLICANT ACKNOWI.EQGE EN7; �
<br /> � - .
<br /> Agrees t�prtiVitle al!ini4►�tation 1'eqUlred ot r�quested tijr:ttte$uil�'ir5g DeRaitment;
<br /> • Csrtifles that the uiiormatlor►supplied is thhie ar�i c�rrect to the b�of hislh�r knbViAedge. The apRlic�rtit_.reGognites tYtat,fhey aa`e
<br /> s�lely rsaponsible�r submil�rl,g a oompleGe applicafion being aware that upon fiallure to do so,ihe statf has no alternative but to
<br /> reject IE itrtfil it is oomplete;
<br /> • Sarrle or al!of the infom►ation.that yqu are 8sl�ed b ptovide on thi�applica�on ls classified b�Sfa�� !aw as ejthe�private or
<br /> ppnfldential. P.rivate data is i�fc�rmadon whictl',generally cannot be given to fhe publlc but can,be given to the subJe�t of the.daka,
<br /> CoM'id�tlal darta is infortnation whidi g�nerally c�nnot be given to�ither ths public or the$Ubjec�af the def�. Our purpos9 and'
<br /> iMe�ded use of this ilii�ormatio�_ts fio�nnUally update ciur records and reoorGls of pther govemmerrtal agehde$r�qui►ed by IaivvU: If�
<br /> • . u retuse to in ' . :the a hcation ma not be.issued. _
<br /> ApplicAnt's Signature: Date: b
<br /> �wrler's Signature: _ Date: . �� �
<br /> �ast uPaated:osros�2o13 _ _ ,
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