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.� . � <br /> �• - <br /> �ity of Orono <br /> Build�ng Permit ,Applica�ion far Maintenance I Renava#ion <br /> (windovvs, doors, sidin , re-roofir �tG.) <br /> MailingAddress: P�rmif number: �i' � 7^ <br /> �,�Q�,O Po Box ss ,,�1(� — <br /> Crystaf Bay,MN 55323-0066 Dai�e receYed: <br /> Received by' <br /> StreSt Add�Ss: <br /> °i Plen re�lew fee:� <br /> 2750 Ke11ey Parkway <br /> ������,�,� Orono,Mt�553�$ �� _7 , / <br /> Total�ee: <br /> Maln: 952�249�800 Fax: 952-249-4616 www.ci.arono.rr�;us <br /> 'fhis application form mus#be completed in fuil and�II requir�ed infiarmation must be submitted. <br /> Incomplete 8ppli�atlons wi11 be returned. (Pl�ase prin#) <br /> G�NER.AL 1NFORMATION: � �`I ���^ ��,�� � �� <br /> Job Site Addresg: <br /> Will this be a Par�de of Homes, Remodalers 3howcase Home br o'ther Display Home? ❑Yes Na <br /> (f yes,a Spe�qui�d�nle 8 appl�ic�nt demonPo/t�Dufflc ent on s��ng 1 a'v��lab/e�f lVon-pe1'mltted ev6nts Wr7!not b�!lowed eNlCe wi11 b9 <br /> CONTRAC�"OR/APPLiCANT lNFORMATEON: <br /> Name' 1� \ 'A�-�'�S.er� <br /> Statie�icense# �C..\3��� Expiration Date: � ';(� <br /> Leatl CerCification Number: �j � r� a g 3 � Expir�tlon Date: �({(� _ <br /> (fo�work�n homes thae were aons�cted prior to 1978� ��c�' (Ge8) � <br /> Phone: (�5�� a� —�O�' �t ZIP: S54 <br /> M�iling Address: �q �,_, , '� "G" WE�- City;�,p� ; � <br /> Contact Person: Applic�tnt is �n ct I Fi�meowner �c��ie onB> <br /> Em�li andlor Fax: <br /> PROPERTY OWMER 1NFORMATfON: <br /> Name: � rY�'� . <br /> Phone (day): (�- !4 � zIP: <br /> Address: ���. <br /> Email at7dlor Fax <br /> PROJECT IN�'ORMCATION: Any earth movemertt may requlre <br /> �71P�oY Project: � MCWD revlew$permits: <br /> ' ❑Door(s) ❑Remodai []Fire Damage Minnehaha Craek Watershed Dlstrict(MCWD) <br /> � Starm Dama e 18202 Minnetonka Blvd <br /> Q Fts-raof,asphalt []Repair ❑ 9 peephaven,MN 55391 , <br /> ❑ Re-roof,ced�r ❑t�estoration ❑Wetsr Dsma9e Phone: 952-471-0590 <br /> Qther. (spec ) � Fax: 952-a71-0682 <br /> [�R�roof,oth�r(sPectfy) ❑ Siding � �� �� � ,,,,,,y,,y rninnehehacr�ek.a�rr , <br /> �Window(s) <br /> Overatl Project�escription: n ' �'r � - <br /> Estimated Construction Valuat;on of�roject excfudin tand S `�' � <br /> APPLtCANT ACKNQWLEDGEM�NT: <br /> . Agrees to provide a!1 in�ormation required or requested by the Building D�partrnent; <br /> Certlfies that#he lnformation suppiied is irue and correct to t1'�e best�f his/l'�er knawled�e. The applicant recogntaas that ihey <br /> • are so161y responsibie for submftting a complate application being 8ware tE'iat upon faiiure W do so,the staif h9s no altem�t4ve <br /> but ts�reject it until it is complete; <br /> . SomA or all of 2he inform�tlon th8t you �re asked to provide an this appllcatt4n is Classified by State faw as either private or <br /> canfitiential. Private dat�is infiormation wtiiCh �eneraily Cannot he g'sven to the public but can be given ta the Subject of the <br /> data. Confidential data is Information which generally cannot be giv�n to either the publEc or the subJact of the data• Our <br /> purpase and lntended vse of this informatfon is to annually upda'te our records and records o'f other government�f agencies <br /> re uited b faw. If u refuse to su i the inforrnation ths a lication ma not be issued. <br /> Ao�iicant's Sianature' <br /> Date: ��U I� 1�" <br />