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City of Orono <br /> y �- Building Permit A lication f ' � <br /> , pp or Maintenance / Renovation <br /> (windows, doors, sidin , re-roof, etc.) <br /> O Melllnq Add�sss: <br /> O'�" � PO Box 68 Permit number: 020/cy�-�7 <br /> � Crystal Bey,MN 55323-0066 Date teoetved: �- -/,� <br /> � � Streer Address; Reoeived by: <br /> 2750 Kelley Parkway Plan revtew fee: <br /> � arono,MN 58356 <br /> Main: 952-249-46pp Fax: 952-249-4616 www.ci.orono mn us Total Fse: �//�qr�/ <br /> This appiication form must be completed in full and all required irrformation must be submltted. U <br /> QENERAL 1NFORApATION: ��m����plications wlll bo retu�ned. (Please prrntJ <br /> Job Site Add�ss: p�q 9 Q S(��js.�� <br /> Wiil this be a Parado cf Homss, Remodslsrs Showcase Home or other Display Homa? y� <br /> �r�s.a s�c�a�e�r�►n rs►�r�,ad wnrn�oe�.n,�eM e,►�r c�y co�„di No <br /> reqWivd uNess a�csnt demonstredes sulRcleM on-slte °p��e0 dal�Arior to Nie evgr�t. Shutde bva seMce wiU 6e <br /> Aar�n9 fs eveNeb/e. Mon-permfKeal eHents w!N not be sl/ow�ed. <br /> CONTRACTOR/A�CANT iNFORMATION: <br /> Name: � t f�� <br /> State�icense# G13o9 <br /> Lead Certification Number: �P�ration Oate: 3 f 3t <br /> �'AT- oZ�-o?83 - 1 Expira�on Date: - y J� <br /> (lor w�ork an ho�mes tliat waro cor►structad pr0or i�f978 <br /> Phone: f�S1– o� 04—y��.'} (offive) <br /> Mailing Address: � � �� •• Wc Ci ����� <br /> Contact Person: ry� ► G 21P: S <br /> Erna(I and/or Fax: APP►icant is: n / Horneowner tarci.on.� <br /> PROPERTY OWNER INFORMqTIpN: <br /> Name: • ���,� <br /> Phone (day): — <br /> Address: — -' <br /> Email and/or Fax C�y� ZIP; <br /> PROJECT INFORINATION: <br /> Type of Projsct: <br /> ❑�oor(s) My esrtb movemsM may roquire <br /> ❑Remodel ❑ Fire Damage MCWD roWsw$psrmlts: <br /> ❑Re-�oof,aspha�t ❑Repair ❑Storm Dama Minnehaha Creek Watershed District(MCWD) <br /> � 18202 Mlnnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoratlon ❑Water Damage �eephaven.MN 55391 <br /> ❑Re-ro�f,other(spscN:t�) ❑Siding ❑Oth�:(specify) Phone: 952�71-0590 � <br /> Fax: 952-471-0682 <br /> _ �Window(s) w�v.minnehahacreekoro <br /> Ovarall ProJ�ct D�scription: W� <br /> Estimated Con�truction Valuation of Proj�ct .xcludln land) S s '} t� � �S . � <br /> APPLICANT ACKNC�WLED�3EMENT: <br /> • Agrees to provid�all intomiatbn required or requested by the Building Departrnent; <br /> • Cerdtiea thet the informatlon supplied is true and correct t�the best oi hfNher knowle e. The <br /> are solsly responaN�le fo�aubmieinp a camplete application being aware that upon fail re to do so�the staft as�o�eltomefive <br /> but to reject it until�ts complete; <br /> • Some or all of the infomiation that you are asked tC <br /> oonRdentiel. Private deta Is inf�rmadon whlch generalply cadnrqt be ghrenllE�o tl�is pubf�b��y�i��� �e�� a�e <br /> date• ConfidentiFal data is iMortnation which genera��y ca�rqt be 9iven � e�e� the public or ihe subject of the data. Our <br /> P�rPose and intended uge of this fnfortna��on is to annually update our reconis end record8 ���� �py��� a��� <br /> __ required by law If ou rafuse to su I the intormetbn the a licatlon not be issued. <br /> �nolicanYs Sianature: (,�"7 �'� ,��.(,�.. <br /> ��� �te: � {�� lc� <br /> Z 'd 06T94L9TS9 3�IA213S 1IW213d Q R S I� �i �9T ZTOZ EO `��ki <br />