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City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> windows, doors, sidin., re-roof, etc.) <br /> Mailing Address <br /> it <br /> 4i14' PQ Box 66 i Permnumber: c e/ - 6 63 2 S' <br /> PI <br /> Crystal Bay, <br /> _ , Bay,MN 55323-0066 `i <br /> / � Date rive <br /> d: - / — <br /> �� Received by. <br /> fJ1,, ,v _z. �i� Street Address: <br /> 2750 Kelley ParcwayPlan review fee:roDrano,MN 55356.� � Tctat Fee: .1"-.70'3--/—.----g3--- <br /> Main: <br /> � <br /> /—. 3 JMain: 952-249-4600 Fax: 952-249-4616 O O,: no.roo soli <br /> This application Forri must becamploted in fu ertd-a required information nriuSt be SubMitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: /PT Al <br /> Will this be a Parade of Home*,Rete to Showcase r ' a • y o <br /> "'Yee.a special event permit os, ,,,r d wtn Police " a o other bis, �y Nome? III Yes 7 No <br /> required union Department and City • <br /> Counrsf approve!Sd days Prix to iris event. Shuttle Pus -:• ..-wen be <br /> t demonstrates sufficient an-tote perking cs evallabi . N Non-perrnibed events will not be allows <br /> CONTRACTOR/APPLJCANT INFORMATION: <br /> Name: <br /> 64tiver SerY1Ce 5 <br /> State License# 13C SP$Otsisi <br /> Lead Certification Number: LE 3Cf57) --.— Expiration Elate: 3/3//1S <br /> (!or work on homes that were constructed prior to 1978 Ex Btlt]ft Date: -/ -/ <br /> Phone: 7Ze3-9 / -i7a3 (office) 7(03 - 567- 2. <br /> Mailing 910 (c:81 <br /> Contact Person:, 4 foe r'Za'Zz1 - W-4.` City: keL, ZIP: ,5�.3 a 3 I) <br /> Email <br /> Contact <br /> Fax: Applicant is: (Contra I Homeowner minis,o„y <br /> I ccia 0zz a etkee-s-ervtce.5•/,G, cam — 16,3- y27- 433 <br /> PROPERTY OWNER IN <br /> Name: ?7d�� „ j,. .., <br /> Phone(day): I . - -20(0 1��'rD -38'0-30 O9 <br /> Address: __.:(2/../ "jam;`:�i <br /> Email and/or FaxrL, %DYVS ZIP:,53-3 bc� <br /> PROJECT INFORMATION: <br /> Type of Protect: i 1 <br /> D Doos Any earth movement may require <br /> � ) Q Remade! Q Fins Damage MCWD review a permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> CI Re-roof, asphalt Q Repair 0 Stomp Damage 18202 Minnetonka Blvd <br /> Q Re-roof,cedar 0 Restoration <br /> Water Damage Deephraven,MN 55391 <br /> ❑Re roof, other(specify) :larding 0 Other Phone: 952-471-0590 <br /> (aPedfy) Fax: 352-471-0662 <br /> ❑Window(s) rarer 'o_!ne ahper�ck.or_g <br /> Overall Project Description: Reed i r GtIt/Gr dot i <br /> Estimated Construction Valuation of Prat(excluding land $ 55 D <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied to true and correct to the beat of hisi1hei kna <br /> wledge. The applicant are solely fespansibie fir submitting a complete application being aware that upon failureto do so. the start recognizes that thy <br /> but to reject it until it Is complete: hos no alternative <br /> • Sorne or all of the information that you are asked to provide on this apps vatic n is classified by State lave as either private or <br /> confidential, Primate 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 generallycannot be given to either the <br /> purpose and intended use of public or the subject of the data. Our <br /> this information; to an euauy update our records and records of other governmental agenries <br /> required by law. If you refuse to supply the in ' tion,the application rna• not be is d- <br /> Applicant's Signature: 4 , , <br /> Date: 51,41fr <br /> 'Waled: 08-09-201 i / <br /> i abed EE9Z-LZ17-E9L Xed dH Wd617L0 171.0Z 91. -Idf/ <br />