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. c:ity ot orono <br /> � Bullding Permit Application for Maintenance / Renovation <br /> . , <br /> � ' windows, doors, siding, re-roof, etc.) <br /> MeqinD Addrea�: Permit number. � � <br /> �r 0.� PO Box 68 <br /> Q 0 Crysial Bay, MN 55323-OOBB Date reo�ved: �-- —/ <br /> � � SYreet Address: Reoeived by: <br /> � 2750 Kefley Parkway Plan review fee: <br /> Orono, MN 55356 <br /> Main: 952-248-4800 Fax: 952,249-4618 www.a.orono.mn.us Tolal Fee: /��� � <br /> This application form mus�t be oompleted in full and ell required information must be su6rnitted. <br /> fncomple�be applicatlons wlll be returned. (P/ease print) <br /> aENERAL INFORMATION: <br /> Job Site Addre�s: �a cJ `j �`l�� ��(t u� <br /> WIII thia ba a Parade of Home�,Ramodelers 3howcase Home or oth�r Display Hvrr�? Y�s No <br /> Ny�ea,a apecial event pennrY ls reqWred with Polhce DeparhneM and Cily Coundl approval 60 days pNor to ths event. 5hult►e bus sen�lae wUl be <br /> �qulred uMesa applfcent demonstrefea suffklenf on-s/le parking is eveNeb/e. Non�permlfted evo�nte wNl not be allow�ed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: t�,rkl�o.1 �'K ��trSeiN <br /> State License# '�C ti 30 9 S 3 Expiretion Date: 3 j 3� <br /> Lead Cert�Rcation Number: (`j�T- o?�-a83 -� Expiration Date: y Jis <br /> (fbr woNt on honfea thet w�ue conab�uet�sd prlor to f978 <br /> Phone: (05�— o'�(�y—4�'}�- (otfice) (cell) <br /> Mailing Address: �� �• WCy� City: ; C ZIP: s <br /> Contact Person: APPlicant is: / Horneovmer {an�.on.� <br /> Ernail and/or Fax: <br /> PROPERTY OWNER iNFORMATION: <br /> Name: ��,� 1� <br /> Phone(day): �a , � � <br /> Address: ; City: ZIP: <br /> Email and/or Fax <br /> PROJ ECT I NFORMATION: <br /> Typa of ProJact Any earth mowment may rsquire <br /> ❑�Kg) ❑Remodel ❑ Flne Damage NC�review 8 permib: <br /> ❑Re-roof,asphalt ❑Repalr ❑Storm Damage Minnehaha�M���B�c((RqCWp) <br /> ❑ Re-roof,cadar ❑ Restoratlon ❑Wa6er�amage Deephaven,MN 55391 <br /> ❑Re-roof,other(sp�cliy) ❑Sidin Phone: 952�71-0590 <br /> 9 ❑Other:(spediy) Fax: 952-471-0682 <br /> �Window(s�� � C�C/� w�rw.minnehahacreek.ora <br /> OvereN Pro eet Descri ion: • � , <br /> Estimabed Construction Valuatlo of Pro oct(sxNuding land ; _ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provlde all information requlred or requealed by ihe Building Departrnent; <br /> • Certefies that the information supplied is true and correct�the best ef hia/her knowledge. The app�icant recogn�es that they <br /> are solely responsible for submitting a complete application being aware tl�at upon failure bo do so,ihe staPf has no altemetive <br /> but to rejed it untii�is oomplete; <br /> � Some or all of ihe information thet you are asloed to prvvide on this applicatEon Is clasaified by 3te�e law as either privarte or <br /> canftderttial. Prfvate data iB infoRnatio� which generally cerpmt be given t�o the public but can be yiven to the subject ot the <br /> data. Confidentlel data is informetion which generally cannot be glven to either the public �r the subjeci of the dats. Our <br /> purpose and ir�tended use af this informetion is to annually updete our records and records oi olher govemmeirtal agenaes <br /> r� uired b law. 1 u refuse to su I 1he tMormatbn the a lication ma not be iasued. <br /> Aoolicant's Sianature: ���-� ��: �� �Z <br /> z 'd 06T9bG9TS9 3�IA213S 1IW213d Q '8 S I� Z�► �ST ZtOZ Si �eW <br />