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04/15/2013 09:50 9528885554 PAGE 01 <br /> OronoCItY of <br /> Building permit ApplicationMaintenance for <br /> A' Resin Renovation structural ex nsion. Onixwndows, doorsdin re-aoetc.)Y FK4Wng AtltlrssC <br /> PO Box 88 F'�rtriR , <br /> eq tel Bay.MN 55323.0066 Koiltilksl;: , . <br /> 2750 <br /> ar;o Orono.UN 83S8 Parkway5 <br /> Main: <br /> 962-249-4600 Fax: 952-2494816 <br /> This application form muni be completed In full and <br /> inyomPkil"aPPI102tfoes Wilt be air od,dinflor <br /> (Pl se p nt)Must be submitted. <br /> GENERAL INFORMATION: <br /> Job Site Address: <br /> Wilt this be a Farad@ of FlGlnes,Remodelera ovtaase Womtt or other Dlsptay Nome? <br /> it yo,�a apedar event perrnW is r gbh d►wb poWoa Yes No <br /> regfjM 4mb=appftN delttp Wrgw ��"l c4 Coum#epptovel t1, data prior t0 the ev9nf, <br /> aurikiwpf m-C&p4fxV,s&,Webb. Non ps/m#ted arpv�eAf Trot De aAbNed km SaMb WN be <br /> CONTRACTOR I APPLICANT INFORMATION; <br /> Name; <br /> State Lloense# <br /> Lead Certificalion Num r: Expiration Date; _ <br /> (fir wont on Moines tfret wets cOrrstrva PIPE 11,1114to f 8 Expiration Date: <br /> Phone: (cell) 1 <br /> Mailing Address: (office)3aS� <br /> $ $ <br /> Contact Penson: A DIN: Clem <br /> ZIF: t � a1Zt+ <br /> EmaH and/or Fax: pAli�"t's �` clor omeowner tGsnl.p„p <br /> PROPERTY OWNER INFORMATION: ' <br /> Name: <br /> Phone(day): <br /> Address: <br /> Email and/or Fax: CIN: ZIP: <br /> PROJECT INFORMATION: Overall.—I--descri On: <br /> 7C3R9qaof, <br /> ProJact: <br /> s) Remodel ❑Fire Da Any earth movement may also requiro <br /> Damage MCW13 review a permits; <br /> of,asphaR ❑aepalr ©Storm Damage minneheho Creek Watershed District(mcWD) <br /> oeditr ❑Rsstoratb" ❑Water Damage 18202 Mtrmstonka Blvd <br /> W.Other fepegy) ❑Skting Cl outer:(spew) �phev252-471-0595rk MN 1 <br /> ❑Wkidow(s) Fax; 952-471-0682 <br /> Estimated Con9trat:tion Valuation of Project(excluding land) 5 W 'mm�h°nue om <br /> APPLICANT ACKNOWLEDGEMENT; <br /> • Agree*to provide all IMbnnetlon required or requested by the Building Department <br /> • Caitlflas etsi me Infonnwlcn aupplled is true and correct to the best of his/her knowtgog <br /> e. <br /> A79 <br /> reapornlple for eubmktlng a complete applkxaticn bang aware that upon tallure b do so,tiThe de IcBnt te<aM Mpg recognizes <br /> 471he"y <br /> reled k until k is complete:• some or all of the Information that you erg askedtopravldeonthisappNcetlon is classMgd by State law ea N <br /> GOngdahtiet. Pilvett+data Is IrKOrmstlon which garwregy rom>at be elven to the public but can be given to the subJect of the data. <br /> ConMenilsi data re ktlottnatktn whit;generally cannot bs given to slither the pubic or the subject of the date. Our puf the ata. <br /> Intended use of thisInforrnetion le ee annueRy update aur re00rds and records of outer governmd <br /> WAS,11 su the lnfo melon,the Ik:atfan mA not be Issued. ental agendas required by law. if <br /> Applfcanrs Signature; _ ^� _ <br /> _. Date: <br /> Owner's Signature; <br /> Last Updated;03MV2013 Date; <br />