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MAY-15-2012 23:46 FROM:TREBILFOUNDATION SYS 3205938720 TO: 19522494616 P.2/3 <br /> City of Orono <br /> Building Permit A plication for Maintenance / Renovation <br /> �Ill"�dilfig, re-roof, etc.) <br /> IrusPricToRMailln A 5: Permit number: / <br /> O'Q�+01�0 tl�aTeS- .r, °X <br /> Date received: -S/ <br /> PROVIE;,, r i 'ED <br /> ❑ �°PRt;t$�ir1 �,, Received by; <br /> a D NIOT APP:C$ 154 l i"c Plan review fee: <br /> These comments ar !X <br /> G r°, ,All svo�k shah be <br /> f�H cc:,ptianco v;i�i1 a'! ^p:°i�-° t,r:;IC; ' Total Fee; <br /> Main. 952-248 i+�t1nQ',�3, IYE ' 7l <br /> This application I A>i�Wt#u tggired information must be submitted. <br /> Incomplete applications will be returned. (Please print) -t <br /> GENERAL INFORMATION: <br /> Job Site Address: `I p,-, j —7 3 . <br /> Will this be a Parade of Homes. Remodelers Showcase Home or other Dleplay Home? EJ Yes No <br /> if yos,a special event permit is required with Pdloe Department and Cid Council approval 60 days prior to the event: Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking Is available. Mon-permitted events will not be allowed, <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �� �r��s9. 9L.rs +a0 ,• ,.,s <br /> State License# yl♦(6L11 Expiration Date: -3 Z _ )y. <br /> Lead Certification Number. N pZ,-- I p�� �_t Expiration Date: 3.1�- 1 jp TM� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: 3 Q D- 593- -7 ag (office) (cell) <br /> Mailing Address: 1 City; L "_J)CeJA ZIP: <br /> ContactPerson: � ` Applicant is: Qjnfracto / Homeowner (circa.ons) <br /> Email and/or Fax: a. ry,ininSrJ&zla,UDIa,,isrC) ;9,,�;- `g-1ab <br /> PROPERTY OWNER INFORMATION: <br /> Name' <br /> Phone(day): <br /> Address: '-7$D Tpl--,4 � q., c\ City <br /> Email and/or Fax <br /> -......_ }— " A-) <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth i <br /> ❑Door(s) ❑ Remodel ❑Fire Damage MCWD ruviow ON Psenmw: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt Repair ❑ Storm Damage 19202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ 590 <br /> Re-roof, other(spoclry) El Siding Phone: -0 <br /> g Q Other: (specify) Fax. 9522.471--471-08822 <br /> ❑Window(a) www,minn®hahacreek.ora <br /> Overall Project Description: Q' - ^�, CnjJo_+e da, o WaR� �)ra<< <br /> Estimated Construction Valuation of Pro ect(excludln land) $ ! wt <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge_ The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until It is complete; <br /> • Some or all of the Information that you are asked to provide on this application Is dasslfied by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data Is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this Information is to annually update our records and records of other governmental agencies <br /> required bv law. If you refuse to 5u2&the information the application may not be issued. <br /> O <br /> Applicant's Signature: m �+ Date; p <br /> Last Updated: 0"9.2011 <br />