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City of C}rono <br /> Baflding Rermit Appiication for Maintenance/Reptac�mean#1 Remodei— �� t�l."� <br /> (l.e. wincic�ws, dc�rs,�dln�,t�r�-rcaof,�tc.--�#t3 S't'�t3CTURAI.�X�J�IJ�tt�N} <br /> Ma�lfng Aa�lre�s: P�mit nurr�er. a �� <br /> ���� c��i B,ann►s�szs-caoss oa�e r�ei,rea: —5 � <br /> Srreer AckMess: ���: <br /> � �` 2750 Ke�r RBrIc�Y Pian review fee: <br /> `� � Orono,MN 5535B <br /> t'��FSHo�� Total�ee: c�,l.��.� � <br /> Main: 952-249-�#B00 Fe�c 952-249-4618 ,�,, ,mn.us <br /> This application form must be campketed in full a�d all�ec�uired i�form2��n must be submi#fied. <br /> incomi�ts aPPlMatior�s wiit be retumed. (Pte��e prinr) <br /> GENERAL�VFORMATION: <br /> Job Site Address: 'Z � C�O (� �� •�UG' N C9 ro'�++�o N't S���� <br /> WIl1 this I�e a Rarade af Nomes,Hemt�delers Showcase N�ne or a�ther Dis�tay Hama? Yes No <br /> If yea,a eve,�p�t�►eq�red w�Fr� �d c�y cor�nat epp�av�t 8o a�ys pr►a to ure eue�. Stxd�e txls eervace w�be <br /> requirad ur�ess a�d�rN t�sullk�e►►t a+-srte pavktng�mr . Nan eve�w!�rlot 6e aN�w+aol. <br /> CONTRACTOR/APP�IGAMT INF��ItAT{ON: <br /> Natne: t.,v..�\�cy..w-� �(`'"Y `�c'" <br /> State License# Eacpiret�t�Date: <br /> Lead Cert'�"ic�ian Number: E�irati�n Date: <br /> {rar wvo�t on norrrs�atar«rero con�rru4�rcr odor ro t978 <br /> Pno►�: ��t�> �,t z.- Yr� - �s- go t�"�) <br /> AAailing Add�ess: 2.t{�p � r„3+ ,q�,� N CityY: b�oN..c� Z[P; �S 35� <br /> Corrtact Pet�son: '���l i y i-r t"" APpltcant is: Contr�dor / tc�ony <br /> Email andlor Fax: �-,,1� e b► 1� "'�.,y ��r. c o�`^ <br /> PRQPERFY t}WNER INFORMIITION: <br /> Name: S A � 1� �tt -`T�► �cr <br /> Rh�'te�(da�r): �,z t Z. - x,� - :�� �f.`� <br /> Addr�ss: '�,_1 L�C? E� T-� /� v� 1�.) ��hr• �f l3d?G� ZIF': S.S�.�� <br /> Email and/or F�x: �n i 1\ � �.\t '"T�+ t C'f , �� r-� <br /> PROJECT INFORMA�ON: �verall r ' descxi ion: <br /> Typs af Project: Any earEt�mavemeM may slso roquiro <br /> O�oor(s) C]Rernoael ❑Fire oen,� �icwD rovi�w�c permtu: <br /> ❑Re-�oof,asphaft ❑Repair ❑Storm D�n�e Minnehaha Creek Watetshed D�trict{MCWD) <br /> 15320 Minnetonka Bivd <br /> ❑Re-roof,ced� ❑Restaratiar► ❑Water pam�e Minnetonka,MN 55345 <br /> ❑Re-roof,otner t�c�ty) ❑s�din� ❑ott�sr:tspec�y? �s: �s2-a7�-45so <br /> Fax: 952-�7i-0682 <br /> ��,,Windowts} v�rrw.minnehah� .cx+� <br /> Estlmatad Construction Vatuation ot Project(e�ccludirtg I�c� � �'c�vo, o <br /> APPLiCANT ACKNOWLEDGEMENT: <br /> • Agfees t�prov�e atl inf�►madon required w roquest�by the BudiMing Qepartrne�t; <br /> • Certifles that�re iMormadon supplied Is true and cocrect to tt�e best af h�r . The ap{�icar�t re�gnizea�at they are <br /> sd�y r�ponsible for sutxnitting a cwr►p�te a�lication being aware thst upon fa�lure to��.the ataff h�no alternativ� but ta <br /> reject it until it is compiete; <br /> • Sorne or all of#he informatian that you are asked to provide ai tl� a�lication is classif�! by State lav++ as either p�ivate or <br /> co�f�ential. Private data is i�rmatian v+A�icfi generatly cannot be piven�the pubi�but can be g�r�to the subject of th+e dat�. <br /> Confidential data �infonnation wt�ic��ne�{ly canr�t be given to etther d�public or the subject af the data. Our purpose and <br /> intended use Qf this in�rmation is to anrxtaAy updat�our recsards end reconds a#od�r'gov�ammer►ta!agenci�raquired by iaw. If <br /> ai refuse to s tlie in ation a lication m� r�t�i�sued. <br /> Appticant"s Signature: , � t)ate: � "�' �� RECEIV�� <br /> �` ;.��'""��' �: � ... ,�---r�' <br /> t7wner's Signature: .- _ •••" " ` z01� ' <br /> Last Upd�ted:January 2018 <br /> CITY OF ORONO <br />