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�/2 2012 wsn 10: 23 FAx 555 5555 Tinuoerline xoofing f�p01/001 <br /> � <br /> City of Orono . <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, sidin , re-roof, etc.) <br /> Ma/ling Addres�.• perrnit number: �!a�. <br /> �O�0 Cryetal Bey, MN 55323-0096 Date recelved; 5 � <br /> 5heet Add►ess: Received by: <br /> � 2750 Kelley Parkway Plen revlew f�e: <br /> � Orono, MN 55356 <br /> Total Fee; � �3�, �� <br /> Main: 962-249-4600 Fex: 952-249-4616 www.ci.orono.mn.us <br /> This application f�rm must be completed in full and all requlred infonnatlon muat be submitted. <br /> Incomplete appllcatlons wlll be�etumad. (Please print) <br /> GE ERAL INFORMATION: �+ <br /> Jo Ite Address: (1 y JU$S�C �• <br /> IWII hls be a Parade of Homee�Remodelers Showcase Home or other Display Home? Yes o <br /> ,e spedel evenr perml�la�eaulred wlfh Pollq DepeRment end Wry Coundl approval 60 deys pnor b ths event Shuttle Dus aervl w�ll de <br /> _ Ii , _ , , roqulred unleaa appl�enf dernoneMafea eu/Ac►ent on-erle perMng la 6�aileb/e, Nonyoe►m/Hed evenfe will nof be el►owed. <br /> 0 RACTOR I AppLICANT(NFORM TIO � <br /> a : Tf/ttibdb�l��'i( � �liny <br /> ta License# 8G(�317�1�j Expiretion Date' � y � � <br /> ea CeAlflcstlon Number; ��� �/y(,6�—� Expiretion Dete: � <br /> r wcrk on homaa thet w�ar�e oonabucted prlor tn 1878 <br /> ho : �{,S"2— 92 b�/9/0 (��) �S/— 3 �/� (cell) <br /> sil g Address: ,S'US/ ' 7 // ' 2 D City: / �• ZIP: ,�Sy/ <br /> on ct Pe�son; �� ApplicanE is: o / Homeovmer �cw�ro o�.� <br /> m i and/or Fax: � /! D = Q -- —1 <br /> i�R ERTY OWNER INFORMA710N: <br /> �Na : �rha�rd Br�r <br /> �ho (daY)�� 1� '7n— 4UOy <br /> dd s; ,3p�VS.SG�' RD�• City: (',�rpr�p ZIP: �,S �(p <br /> me I and/or Fax <br /> R ECT INFORMATION: <br /> • f pro)ect: Any earth moveme�t may roqulro <br /> d r(s) ❑ Remodel ❑Flre Demape MCWD rovlew�permita: <br /> Minnehaha Creek Watershed District(MCWDj <br /> R of,aephalt ❑ Repalr (]Storm Damaqe 18202 Mlnnetonke Bivd <br /> R of, csder ❑ Restoratlon ❑Water Damepe Deephaven,MN 55391 <br /> Phone; 952-477-0580 <br /> R oof,other(op�cliy) ❑Siding ❑Other.(apeaiFy) Fax: 952-471-0682 <br /> ❑Window(8) �•minnehahae�eek.ora <br /> r I Pro ect Descrl tlon: . <br /> . <br /> I ted Const�uction Valuation of Pro'ect excludin land) $ Od <br /> P I ANT ACKNOWLEDGEMENT: <br /> • Agr�s lo provide all informetion required or requesled by tha Building Departmont; <br /> I . Certiflee that!he Informatlon supplled Is true and corcect to the best of his/her knowledge. The appllcant recognlies that iAey <br /> are so�ly responaible for submltting a complete applicadon being aware that upon failute to do so,the staff has no al�e�native <br /> I� bui to reject It untfl It Is complete; <br /> �� • Soma or all of the Infonnetlon thet you ere aeked to provlde on this eppllcetion Is claeelfied by Stete lew ae ekher prlvate or <br /> i nfdential. Privste data is inFormation which generally cannot be given to ihe pubhc but can be 8iven to the subject of the <br /> ` ata. Confidential data is information which gene�ally cannot I» piven to aithe�ths public or thv subject of the data, Ou� <br /> urpoee and Intended use of thls Informetlon Is to ennuelly update our recorda and records of other governmental egenclea <br /> ulred b law. If ou reFuse to su I tha info ation ths a licatiom m �ot ba issue . <br /> , r / <br /> �bli t's Signature: D�ts: ✓ Z,3/� 7 <br /> i .�'li�� �� na.n��n�, <br />