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� � � � City of Orono � � ��:�j ::_�
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<br /> . Building Permit Application for Maintenance ! Renovation ; �,
<br /> . , , ... � �.�_._
<br /> (w�ndows, doors, sid�n , re-roof, etc: , � �:.
<br /> �O� Mall/ng Addross. 1 ,
<br /> PO Box 86 Permit n umber: � 0�0/.�=D t�0/I�
<br /> � Q Crystai Bay, MN 553Z3-0068 d�e���: /-.�,�y�.
<br /> � g Street Addnass: eoefved by:
<br /> -a,.. '� �' 275p Kelley Parkway �
<br /> 044' Oronc,MN 55356 lan review.fee: _.. . .... _.......,
<br /> .a -
<br /> Me(n: 952-249-4800 Fax: 952-249�616 w�av_ci.orono mn us !Fee: �/,�� a 9
<br /> _....
<br /> 'This application fortn must be completed in full and al!required inform �on must-be submitted: --�...
<br /> Incomplote applications wtll ba rotumed. (Pleas�pr�nt)
<br /> GENERAL INFORMATION:
<br /> Job Sibe Address: p��9 'S(A S♦J�. I � - _ _._._ .___.
<br /> ;MUfll thls be a Parade of Homes� Remodelers Showcase Home or ather Dla j� €
<br /> Ks�.a speda�e,rem�m,n rs requ�r�d wrn��a►�ne P�aY Home? � Yea _No
<br /> uired unlesa �rt�and City CouncYl approvel 60 dsya priorto the eNant �ulMe bua senn�Ce Wql be '
<br /> �9 aPpl'�carM demonshates auMclem on-mi�e perkfng/s eveNabie. Nonyoermitted eye►rta wip no be allowied. �
<br /> �CONTRACTOR/AP��PLICANT INFORMATION; I
<br /> -�Name: A rS�e�V
<br /> .�tate Lioense# . '$C130q$ Expira�on , t�: 3 3
<br /> �Lead Certlfication Number. �j,�-`_ a�.a83 - � Expiration Date: y
<br /> _ _. .
<br /> ..
<br /> (Ibr work on hon►as �hat wsre conatructrd
<br /> " P��[01978 ._
<br /> �Phone: �05 I- a�-��-�-� �off�, .�
<br /> , __. _.. .�oeu}._..
<br /> Mailing Address: ,• •• We City:
<br /> Cpr�tact Person: ; C ZIP: c
<br /> Email and/or Fax; Applicant is: nt /- Homeowner �ci�.o,,.� -
<br /> PROPERTY OWNER INFORMATION: �+ — � � � �
<br /> _ a�r•r, ,k,
<br /> Name: �'e. �.C�.t In�,
<br /> PRone(day): „ �� � �
<br /> �r' �
<br /> Add�BBS: ��7:�C �,
<br /> Ernail and/or Fax City: , � Z�p; �
<br /> __... .. . . )f . �i 21t�t i
<br /> .. . . -. .. . :. - -- -` . ,y .
<br /> � PROJECT INFORMATION: _ _ _.___ . ... .
<br /> TYPs of ProlaCt: , _�
<br /> ❑ Door(s) Ahy�artl� ei�t may requlre
<br /> ❑ Remodel ❑ Fire Damage MCWD nevfow a psnnite;
<br /> ❑ Re-roof,asphslt ❑Repair Minnehaha Creek Watershed District(MCWD)
<br /> ❑ Sform Damage ,_
<br /> ❑ R�%roo`�, cadar �:� i:s ��._ . ._ _. _.�_:,� _.__ -_... .. �. ._. '� : 1$202 Mifu�eEonke Bl.vd�._ , _
<br /> tu
<br /> ❑`!`testoralion ❑Watier Demage Deephe�ven, N 55391
<br /> ❑ Rc�roof,othar(.psePty) ❑3idi . P�e: 952 71-0580
<br /> �9 , ❑ Qlher. (specify) Fax� 952-4 1-0682
<br /> ❑Window(s) , n k.
<br /> Overall P eat Description: t a� 9 w; w (Q d paS W 1 h
<br /> Estimated Constructb�Valuati o n o f P ro ��5 .
<br /> (excluding IancQ ; �(�� � �
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • A9rees to provide all ir�ormaqan requiFed or�eq�ested by the Building Deparbnent; +
<br /> • Certifies that the infortnatfon supplied is true and correct to the best of hieJher knowle
<br /> are solely respunsible for subrnttting a complete aPplication being aware ihat upon failu�bo do so,pthe stafF�h�asnno al�temai e
<br /> but to reject it undl it is complete; �
<br /> � Some or ali of the information that you are asked to provide on this �
<br /> coriflldential. Private data is irYformation which pp�bO� �Sf��d by 5tate law as either private r
<br /> data. Confidentisl data ia information wh�h �����y �� be ven to the p�lblic but can be g(ve� td'the subject of t e
<br /> generally cannot be given to either the p blic or the subject of the daha. r
<br /> purpose and irrtended use of this infom�a�ion is to annually updarte our necords and s pf oth�� po�,,emme�ta� age�p g
<br /> re uired b law. !f u refuse to su I Ihe information the a �abo�ma not be Issued
<br /> AonlicanYs sianature:��,,p� ���,p�,�� y��� 1 ,
<br /> Date: �
<br /> z 'd 06i9�G9TS9 3�IA213S lIWa3d Q '8I S M 9E Ei ETOz t+0 UeC
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