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. � <br /> ' �� <br /> ;City of Orono <br /> Building Permit App�ication for Maintenance I Renovation <br /> (windows, doors, siding, re-roof, etc.� <br /> �O� MaNing Address: Permit number. � 3—Oa T 7 <br /> PO Box 86 �� � <br /> Q Q Cryst'�q�l Bay,MN 55323-0066 �ale reoeived: �/� <br /> � � =-,;� � Stneel Address: Reoeived by: <br /> " �� �,� 2750�Celley Parkway Plan re+riew fee� <br /> ��Hp4�' Oronqr,MN 55356 <br /> Main: g52-249-4600 Fax: 952-249�{616 www.ci.orpno.mn us Tota!Fee: �/�0�, Z� <br /> This application form must be co►npleted in full arzd alf required information must be submitted. <br /> Incomplets applications will be retumed. (Please print) <br /> GENERALlNFORMATION: ;; 5}l�r V�,I.�l� �r� <br /> Job Site Addre�s: <br /> Will this be a Parade of Homes,Remadel�rs Showcase Home or o�Display Home? Yes No <br /> lI yas,a specla!event pemiif is required with Polfce Dypa�tment and Gity CounclJ apprnva!60 days prior to the ev�ent, Shuttle bus servfoe wr71 be <br /> required unless appticarrt demonstrates syMf(cierit orrslte parking is aveHeb/e. Non�permitted ev�nts wIp not be e!!or►sed. <br /> CONTRACTOR/APPUCANT IAIFQRMATf01�: <br /> Name: �.�, � ,A ,t�Ser� <br /> State License# "�G1309$'3 � Expiratian Date: �f 3� <br /> Lead Certification Number: �j,A-('_ a��83 -1 Expiration Date: � <br /> (!ur worlk on hwnes that wero constructed pribr to t g78 <br /> Phone: (05�� a -y�.�}`�. (office) ���� <br /> M�iling Address: , 'i �► �• : ey� City; ; C ZIP: $S <br /> Contact Person: Applicant is: ntra / Hvmeowner �ci.cie one� <br /> Ernail and/ar Fax: <br /> PROPERTY OWNER INFORMATIO : <br /> Narne: .�7 ;' � <br /> Phone(day): ,{,� <br /> Address: ' Ciiy: ZIP: <br /> Email and/or Fax <br /> PROJ ECT lNFORMATION: <br /> Type of ProJect: <br /> I►ny earth movement may require <br /> � �KS� ❑Remodef `Q Fire Damage MCWD revfew 8 perntits: <br /> Minnehaha Cresk Watershed District(MCWD) <br /> ❑ Re-roof,asphaR ❑Repair :,[]Storm pamage 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ��]Water Damage �phaven, MN 55391 <br /> Phone: 952�77-0590 <br /> ❑ Re-rvof,other lsPe�Y) ❑Siding ;�Other:(specifY) Fax: 952-4T1-0682 <br /> ❑Window(s) www.minnehahec►eek.ora <br /> Overall Project Desorlption: W �� � � � <br /> Estimated ConsUs�ction Vaivation Project'�xcludin land) � ,�.� � <br /> APPUCANT ACKNOWLEDGEMENT: <br /> • P�qrees to provlde al!inf�rmation r�equired o�r+equested by 1he Building Department; <br /> • Certifies that the informatlon supplied is true and Conect to the best of hislher knowfedge. 7he applicant recogniaes that they <br /> are solely responslble for submitUng a compfete application being aware that upon failure oc do so, the slaff hes no altemative <br /> but to reject it unGl rt is complete; <br /> • Some or all of the information Mat you are asked to provide on th� applicatFon is classified by S�te law as either priyste or <br /> confidential. Private data is informatlon whi¢h general�y cannot be given to the pubbc but cen be given to the subject of the <br /> data. Confidential data is in6orrr�ation whicFi gener�ly cannot be given to either the public or the subjec� a{the data. Our <br /> purpose and irtit ded use of this inFormatior� is to annually update our records and reoord5 of other govemmental agencies <br /> uired b �aw. I u refuse to I the infom�adon,the a lication ma not be issued. <br /> AcaQlfcanYs Sianature• � ��7 ��: 1 f�'�(�y��� <br /> , !! <br /> Z 'd 06i9bL9TS9 3�IA213S lIW�l3d Q '8 S M SZ �8 ETOZ I T �nC <br />