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f �� City of Orono <br /> Building Perrnit Application for Maintenance / Renovation <br /> , <br /> (windows, doors� sidin , re-roof, etc. <br /> MaUing Address: <br /> �0� PO Box 66 Permit number: / �d�d/ ' <br /> Q � Crystal 6ay,MN 55323-0066 p�e��: �- � - <br /> � � Street.4d�digas: Received by. <br /> 2750 Kelley Parkway Plan review fee: <br /> �' tta�t' Orono,MN 55356 <br /> Main: 8b2-249-4600 Fsu 952-249-4618 w�vw.ci orono mn us Total Fee: � / S3,O I <br /> I � <br /> Thls application form rnust be oompleted in tu►I and all required infomiation must be submitted. <br /> Incomplete applicatlons will b4 roturnod. (Please print) <br /> �iENERAL INFORMATION: <br /> Job 3ite Address: � U� �('±� <br /> WIII this ba a Parade of Homes, Remodelers Showcaso Home or atl�er Display Homf? Yea No <br /> �Y�,e speclel eventpermif!a requiied wlfh PoNce DeperhneM and C!ty Coundl epprove/BO dslm P►la'to the eNent Shutlfe bua service wiY be <br /> ►eqWred unlesa epplkant demonstrsies aulRclent on-slte AarklnD la avaNable. Non�oermHf�d evenle w!N not ba a/lowsd. <br /> CONTRACT�R/APPLICANT INFORMATION: � <br /> Name: t�trlt�'�a.\ �+l A�{rSer� <br /> State�icense# �G13o9 83 Expiration Date: �y �31 <br /> Lead Cefification Number. N�pT- a�.a S 3 -� Expirativn Dete: y�15 <br /> (fbr worir on Aomes bhai rv�re construct�ad pnio,r to 19�8 <br /> Phone: (p51- o� -4� � (office) (ceU) <br /> Mailing Addr�ess: � •• •� Wey,�. City: ; � ZIP: s <br /> Contect Person: Applicerrt is: / Homeowner �ci�sone� <br /> Emall andlor Fax, <br /> PROPERTY OWNER INFORMATiON: <br /> Name: �.e. SO � <br /> Phone(day): a — �, <br /> Address: rj� City ZIP• <br /> Email and/or Fax <br /> PROJECT INF4RMATION: - - . __.. <br /> T��P�O��' Any sarth mowmeM may requin <br /> � �OOKg) ❑Remodel ❑ Flre Damage MCWD nWew d�permits: <br /> ❑ Re-roof,asphal! ❑ Re air Minnehaha Geek Watershed District(MCWD) <br /> P ❑SG�rm Damage 18202 Minnebonka Bivd <br /> ,._ _ ___ ._. ._ _.._ _ _ _,_ _ <br /> []Re-roof,cadar ❑ Res3oi�ation ❑ Water Damage Deephaven, MN 55391 <br /> ❑Re-roof,other(spsclry) ❑Si�ng ❑p�er. s Phone: 952-471-0590 <br /> � Pe�Y) Fax: 952-471-0682 <br /> [�Window(s) � �� www.mi�nehahecreek or�a <br /> Overall Pro Descri iom �; O ; <br /> Estimated Construclion Valuatlon of Project(excludln land � $ <br /> — <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • A�rees to provide all informetlon requlred or rBquested by the Building Depatlmen� <br /> • Ce�tifies tha!the infi�rmaUon supplled is true and c�rect to the beat of his/her kno�wledg�s, The applicant recognitea fhat they <br /> are solely responsible for submitting a canplete �pplicafi�n being aware thst upon fsilure to do so,the stafF has no altemative <br /> but ta r�eject ft untll it is c;omplete; <br /> • Some or all oi ihe iriformetion that you are asked to provide a� this appl(cation Is clessified by State law as efther private or <br /> conlirdentlal. Private data Is inFormation which generslly cenrwt be ghren bo the public but can be given to 1he subject of the <br /> deta. Confidential data Is informaGon which generally cannot be given to either the publlC or the subJecl of the data. Our <br /> purpoBe and intended use of this Information is to annually update our records and recoba of other govemrt�t�l agendes <br /> re uired b law. If refuse to su I the(nformatlon the a lication ma not be issued. <br /> AoolicanYs Sianature� �� Date: Q(�' �� <br /> I <br /> Z 'd 06T94G9TS9 3�IA213S 1IW�13d Q '8 S �1 OS ��T zTOZ 60 ��0 <br />