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JUN-8-2017 10:04 FROM:TREBILFOUNDATION SYS 3205938720 T0:19522494616 P.2�3 <br /> CNty of Orono <br /> 8utldtng Permit Applicatlon for Ma➢ntenance/ Replacement/Remod�l— Resldantial �NL.Y <br /> (i.e.windows, daars, siding, re-roof, etc.— NO STRUCTURAL �XPANSiON) <br /> Moiling address: R����i,�� Parmlt number, �,� — vv <br /> ��� �'Q�dx$fi Y <br /> Crystal Bay,MN 55323-0OBB Qate recelved: —�. <br /> st,�or,aaaross. JU� 0 8 2017 Re�i�ma by: <br /> y � 2760 lCoUay P�rkway plan review.(oo: <br /> �r � G�rona,MN 66��,�F ORO /�� �� <br /> �'kFs��o�`� NO 7ota�Foe: <br /> MaEn� $52.249-4600 �ax: 852-249-4618 www.ci.orono,mn.�� <br /> This applicatinn torm must be completed In fu(I and a11 raqulred Information must be submi#ted. <br /> Incomploto�pplicationa will be returr►ed. (Pl�ese print) <br /> G�N�RAL INFORMATION:o'2O,�R /jR� 0 0� �a� ZO�� r�'�/�/ ��� I <br /> Job Site Addrass: <br /> WIII Chls be a Parade of Nomes, Remodelers S wcaSe hI0m9 Or Qthe Display ome? Yes [�No <br /> ff yas,a speciol evont p�nr�il;s rNqulruu w/t��NaNce 17epartment and Ciry Councll spprova!6tl deys prfor to the avvnt. Shulllv Lus cnrvke wil!be <br /> roqulrod unloaa epplrcan!demonstrot�a sut�iabnt an-slto parking ia cvttllablo. Non-pam,;tted�vants w!!1 not bo a�lowed. <br /> CONTRACTOR 1 I ��"4tJT IIJ p q �p�c <br /> N3me: �.� � U �Q.�(.��� � <br /> ,�.._. ._ <br /> State License# � �xpiratipn Date: _ <br /> Lead Certification Number� � r2 � _ Expiration Date: � � � <br /> ffor work on homos that ware con5truCted prlor Pp 1Q78 1 �q �3 <br /> PhOnO' (cell) (pffiCB) ���l J r 3�a � <br /> Mailing Address: ��� Clt � ZIP: 5 5' <br /> Contact Porson: $ Applican Is• Contractor / Hamaowner Ici.�:.0�,1 <br /> Email and/or FaX; fi' Q (,t5''�°j�9�Q.6t, .CO�'►]_ ��� � �"�„��-Q <br /> PRpPERTY OWNEF�I�'ORMATIQN° <br /> Name: L�«r�'s Gva 1� <br /> Phone(day): � <br /> , . <br /> Address: (;W' 401�nPJ �A �'C� City ZIP' <br /> . . <br /> Email and/or Fax: <br /> —�-� - -- <br /> PROJEC7 INFORMATION; Overall ro'ect descri tian; <br /> Type of ProJect; My earth rndve 4n y also requ re <br /> (� Cloor(s) ❑Rqmndal [�Fire Damsgo M�WD ravlaw � ormlta: <br /> ❑Re-raof,asprialt Q�ePair 0 Storm Dz�m�pe Minnehaha Creek Wator�hed Dlatrfct(MCwD) <br /> 15320 Mlnnetonka 81vd <br /> ❑ Ra-roof,�odar �Restoration �]Wster Dam�ge Mlnnetonka,MN 8534b <br /> [I Rr�•roaF,other(�p�city) Q Siding �] pther:(spaCify) Phorte; 952-471-OS90 <br /> F�x: 952�71-0682 <br /> (]Wlnr.lpw(s) <br /> Estfrnated Constructlon Valuatlan of Projeet(excluding land) $ "� <br /> APPLICANT AGKN�INLEDGEMENT: _.__„ <br /> � Ar�reea tn pmvidq all Information required or requested by tha Buildin4 DepaMm�tlt; <br /> . Certifies that the informatinn�supplipd IS trup and correGt to the best of his/her knowledga. Tho appliCant rp�opnizoe that they 8r0 <br /> Eolely rer�ponsiblg for�ubmitting a Compl�to applicatipn boing aware th�t wpon f�llure tp do 60,thp staff has na�lternative bUt tp <br /> reject it untfl it is Complete; <br /> . Some or sll o! the Iniormailon that you aro askad tfl provlde on this application is alaseffiGd by Stat�s law as either priv�te Ar <br /> tonfidential. Private data is information whiCh gonordlly Cannot qq gl�an tp tho public but can be glvpn to tha subjoct of the datp. <br /> Cqniidpntial data is iniprmation which ganerally oarinot be given to 6itlipr the public or the BubJect pf tho data. Our purpose and <br /> intended usc of this information is to annually update our records and racords af ather gpvarnmental agoncies required by law. If <br /> , _youu refusa to supply the informatlan,the appllcatlon may not ba is_suad. __ ,, .., �, <br /> ApplEcant's Sfgnakure: Date: <br /> �wner's Slgnature: Date; <br /> Last Updaled:J�nuary 2018 <br />