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S�� 0�7 2011 10: 38RM HP LRSERJET FRX p• 2 <br /> Ci of �rono °� �, �� <br /> � <br /> '` � • • ' n e / Renov t�on <br /> � Building Permit Appl�cation for Maintena c <br /> � windows, doors, siding, re-roof, etc.) <br /> Maping Address: r= ���_'�� �-� ��� <br /> ,�0 A� PO Box 88 _ �-~� '-.�.�.-,�-.�__-.__% ,� <br /> O `rO Crystal Bay,MN 55323-0068 _:��.- ....W.�:e=-,��; • ' <br /> Street Addness: �,�a r�.�.:>�, <br /> � � 2750 Kelley Parkway � j'�����.���=�y��"�� <br /> .. ::�. �":�i`¢:,y:!.,a�. i w- z�;,_ <br /> � � �:. <br /> � Orono,MN 55356 ,��__._ . .;�.,,;�. � <br /> ::1��• f�......�..�..'� <br /> �.9'.X.. :�C:. <br /> Main: 952-249-4800 Fax: 952-249�816 www.d.orono.mn.us — - , : -- <br /> This application fornn must be complebed in full and ail required information must be submitted. C�7 if j� , <br /> Incomplete appllcatlons will be returnsd. (P/ease prin� � <br /> GENERAL INFORAAATION: ���-- �- a"'� - � <br /> Job Stte Addr�s: .3��5 �i.dr$�`n e r• � - <br /> Will this be a Parede of Homes, Remodels�s Showcase Home or oth r Display Home� yes No � r <br /> If yaa,e apeael evsnt psnN[is requhed wl�h Police DepsRment and Cify Council epprvva/60 deya prlor to bhe event. ShufNe bus se►v�e w'�ll be <br /> reqWred uNess applicant demonshatea suHident on�Ms perkln9 is avallable. IYorr-perndit�ed evsnts wNl r►ot be aUowed. <br /> CONTRACTOR!APPLICAfdT INFOR�IA�N: � � <br /> Name: ;,J;P rn.ar, �t o �n Q m Q.1'� �r1L� <br /> State l.icense# Expiration Date. <br /> Lead Cerrtiflflcabion Number: Expiration Date: <br /> (for work on homas U►at Nroro conairuc[sd pNor to 1978 <br /> Phone: ��- - �°�� <br /> cell <br /> Mailing Address: o C�y'/�/'� a k Z�P' <br /> CoMact Person: Applicant is: ont�ractor / omeowner (arcis o�.� <br /> Emafl anci/or Faoc: - 5" - • � � a-� , y <br /> PROPERTY OWNER INFORMATION: <br /> Name: �LC <br /> Phone(day): - �! � `{ ZIP: SS q� <br /> Addr�s: ` � ; C�tY�G.�. �a. <br /> Email andlor Fax <br /> PROJECT INFORMATION: <br /> Type of ProJect: Any earth movement may roquire <br /> �p��$? ❑Remodel ❑Fire Damage ���ew 8�permlta: <br /> Minnehaha Creek Watershed Distrlct(MCWD) <br /> ❑Re-roof,asphalt ❑ Repair ❑Stom'i Damage 18202 Minnetonka 81vd <br /> �Re�oof.cedar ❑Restorafio� ❑Water Damage Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> �Re-roof.o�ther(spselfy) ❑Siding ❑Other (specify) Fax: 952�71-0682 <br /> e��a oa Q�� r � ❑Window(s) www.minnehahacreelc.or+a <br /> r <br /> Overall Project Descrtptlon• <br /> F�tirt�af�ed Constructivn Valuation of Project(sxcluding land) S.2lp S�O � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . A�rees to provide all infcrmation required or requested by the Building Depertrnent; <br /> • Certifies that the IMormatlon supplied is tnie and cairect to the best oi hislher iv�awledge. The applicar�recogn¢es that they <br /> are solely responsible for submitting a complete application being aware that upon feilure to do so,the stalf has no alternetive <br /> but to reject it unUl it Is oomplete; <br /> • Some or all oi the iMormation thel you are asked to provide on thls sppiication is dassified by State law as sither privete or <br /> confldeMlal. Private date is infamstion which generally cannot be given to the publ�but cen ba given lo the subject oi!he <br /> data. Confldendal date is informaYbn which ge�rally cannot be �iven to either the public or the subjed of the data. Our <br /> purpose and irrtended use of this informetion is bc annually update our reoords and �orda of other govemmental agencies <br /> re ui�d b Iaw. If u refuse to s l the information the licetion ma not be issued. <br /> 0�1H�If�A11f�A�IAr1S'i�11YR' f// 1�V�/� ...`��— �'�te. gr�r/� _ <br />