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/ , . <br /> City of �rono <br /> Buildi�ng Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Malling Addrass: Permit�tumber: . <br /> 0,�,Q jV.� Po eox e� <br /> Cryst�l Bey.MN�323-0066 Date,rsceived: <br /> a Street Addr+e53- Reoeived by: ` <br /> ti 2750 Kelley Parkwey p�ut revlew tee: <br /> � �,�� Orono,MN 55356 <br /> Total Fee: <br /> Maicr 952-249-46Q0 Fax: 952-245�616 www.ci.orono.mn.us ' <br /> Thls�pplicstion form must be completed in full ar� a0 required it�ortna#ipn must be submitted. <br /> Incomplete ap#�lications will be retumed. (P/ease print) <br /> I3ENERAL 1NFORMATI�N: q� � waO � y�� <br /> Jab Sit�Addrass: o + � <br /> Wlil thls be a Paratie of Home�� Remcdalers Showcas e or other Display Harrwe'� ❑Yes No <br /> If yes,a specral svent pemllt fs tgqWred with Police Depe►finent and City Councll eppll�va160 days prior to the event. Shuttle bus eerv/CP wiJl be <br /> r�quired WNess apRlicsrrt demons8ate8 SURlclent on-si(e perklnq ls 2vaBaWe. No�pemrllted events w►7l nbt be eNowed <br /> CONTRAGTOR/APPUCANT 1NFORMATION: <br /> Name: t�rr�i,,x3.� 'ay i>��trs•e� <br /> St�teLlcense# C,1�0`�$3 ExpiratianDate: '',�f� <br /> Lead Certification Number: (�j '�- ��-�$3 - 6cpiratibn Date: +�J�� <br /> (}'or yvorK on homes lhet were constracted plior to i878� <br /> Phone: (051� aZ(�}-4 Q S$- �t�Ar� (office) (��) <br /> Mai{ingAddress: '� �•C,•� WeSk G'�Y=t�tv�11�. ZIP: {'aSl 3 <br /> Corrt�ct person: Applicant is: n r / Homeowner tc��on.� <br /> �mail and/or Fs�x: WSo.,c.dd� �l�Lo,niti�a.�f C�w-. - <br /> PROPLRTY OWNER 1N�QI�NAATION: <br /> Name: �(Y1 a'( 1 O O(��7 <br /> Phone(daY)- 4S a -W�1 w 9l01�1 ��: �IP: <br /> Address: � <br /> Email and/or Fax � <br /> PRpJECT INFbRMA,TIQN: <br /> Typ�of Project: Aml 4erth movemerrt may r�quire <br /> �p��(g) ❑Remodel �Fre I��mag� ��d���d`�j�� <br /> Minneheha Creek Wabershed Dishict(MCWD) <br /> ❑Re-roof,asphalt [I Repai� []Storm Dam�ge 18202 Minnetonka Bivd <br /> [�Re-roof,c�dar ❑Restoration �Weter Damag� ��A�ven,MN 55391 <br /> Phan�: 952�71-0590 <br /> ❑Re-roof,other(spectfy) []Siding [��ther.(specify) Fax: 952�71-0682 <br /> wndow(sj www.minneh�.a�t <br /> Overal! Pro Descriptian: �C�GQ �l l..v:r�.ou�S wl�r-� �.QJ1F�i S�+ a i <br /> Estimated Gonstruetion Valuatian of ProJect excluding land) S �5 �`�.G O <br /> APPLICANT AGKNOWLEDGEMENY: <br /> . P�qrees W provlde a!I ir�forma�on required or requested by the Bullding De�ardnerrt; <br /> . Certi�ies that the information supptled ls true and r,orrect to the best of his/her knowledge. The applicant reaognlzes that they <br /> are sdely respons{ble fpr submittirtg a compiete application being aware tFtat upon failure ta do sa,the st�ff has no altemative <br /> but to reject it until it is oomplete; - <br /> . Some br�ll of the information that you are asked ip provlde on this applic�tlon is dassfied by State�aw as e�r prlvate or <br /> c�onC►der�tiat_ Prtvate data is irtformatlon whict►generstly cannot be given to the public but can be giv�n to the subject of the <br /> data. Confider�ttal data is infomtia6on which gAnerally cannot be glven to either the public or the subject of the data. Our <br /> purposd and Infended use nf thls Information is to snnually upda�e our reconds and recOrCSs of other govemmeMsl agenaes <br /> re uired b Eaw. If u refuse to su the Infiormakon the e ication rr� no3 be issued. <br /> Aoo[icant's Sianature: �`� Date: BAPr�t�s <br />