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city of Orono <br /> ung ftfn,dt Application for Maintenance l Replacement i Remo&j—Res4denflat ONLY <br /> ki.e. windows, doors, siding, regoof, etc. - NO STRUCTURAL R 0N). <br /> MORVAddrm- <br /> PO Box 66 ... �_ <br /> Crystal Bay,MN W323-0066 Doe fid: <br /> A stmt Address <br /> 2750 Kelley Parkway Plim review e: � <br /> l 5H04' Orono,MN 55356 <br /> i <br /> Main: 952-249-4600 Fatc 952-2494616 wvvw.�.orono.mn.us � � <br /> This application form must be completed in full and all required utform rt?1t be WAXnftW. <br /> Incomplete applications will be returned. (Please p*i* rev 10l _ <br /> GENERAL INFORMATION: <br /> Job Site Address: <br /> Will this be a Para&of Honm, Remodelers Showcom Hmne or other Day Ham? <br /> t7�t dB117k?fl3i 8 otherpeft is SMAW310, ! <br /> CONTRACTOR l APPLICANT INFORMATION: <br /> Name: <br /> State License# C239 d 87 Expo Date } <br /> Lead Certification Number: 4lttii-�- t{7 I Expiration Elite: <br /> (for work on horses#fiat cons&ucled Poor to 1 <br /> Phone: (cep) --?go — +?09 N <br /> Mailing Contact Person: �3 G city, t, , ZIP" �, 2.1__,x. <br /> /4pplicant is: / Horn owrtet' tatra. j <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION <br /> Name: /moi 1• �- "fit �n ,� s J L <br /> Phone(day): <br /> Arlo: lad G1, fC M � Cy;f�� ZIP ;, <br /> Ems#arA#or Fm �'ti=+-- e i t �� w r _ .,� <br /> , £$ <br /> PROJEEC'T'INFORMATION: Overs : <br /> Type OfAct: <br /> Any earth moveinent may atsd jvmf e--- <br /> 0 <br /> f-0 mss) F Mreview&pe <br /> i <br /> VVersR €, tarQaseg6 he (MOND) <br /> M Y UN s t .. <br /> 0 Remo#3 offer lq*ay�) 0 Siding 0 torr(specify) - 952471�05W � <br /> do s Par. {9$2-47t-M2� g <br /> Estknalwl Construction Valuation of Project.(excluding land) <br /> APPLJcmNT ACKN2WLEDG <br /> EIHENT: <br /> A s to a aA fnfcamatican required or requested by the 63 ding <br /> Cortities that the kfte'raaftn supplied Is true and t to the beat of his/her knowiedge, The, <br /> w.- <br /> # 1*60 itsper�m3g a completespptaYtcan bae3r+8 aware that u4tort 1�ure todosc�."the aff has no 0ltara�iti�re�bvt t5 <br /> -j aoms or aH of the tnfomaetion that you are asked to provide can this appacatlon is ciassifatad b <br /> € etdential. f�v�data is informaWn whl�fa generally cannot be given to the pubi�u but can b y :tata 6-W either pnvsets Cat <br /> 9 y 9 ,givers to..,ti+e <br /> C�ential data is int matt on which c on ereNy cannot be given to hither the public� of the dath. <br /> inter of this Information is to ann tally Watt,our r rds and re rda of otter the sut,�°#the . Ott'pu" t Y <br /> you hast in s pp# information,(no i e�tlr�h rrt t bbR rid � rh rttal agencies c M-dia*. ft f <br /> Date- <br /> L oat 3. .pry 2 <br />