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� 04/16/2012 15:28 9528885554 P�GE 01
<br /> City of �rona
<br /> Building Permit qpplication for Maintenance / Renavation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> �� MaNing Address: ' • �����F
<br /> '� PO Bo i�� rW�u7 ��i'�`�'�`�5'.1 ,�t�; r,4'..�i.�;i:ri•.�`°i�" +r
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<br /> � CntS�'dl 89y�MN 55323•0086 q• .r'r n�',�',I�@P1Y��4.�••�i�:;4.�:�:, •t .t�•• ' �;,
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<br /> aress: ;,,1���1�+�I� c,a;a:� •G:. � ��
<br /> �a 2750 Kelley Parkway ��' ' � � ''�•��� '"'' .
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<br /> o$ Orono,MN 55368 �c �•a..•i���;�,: .',�,�.--•,�'.'"r:,.r•���� -
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<br /> Meln: 952•�48-4600 Fax: 95Z-249-4816 w�nr.c�.a►onomn s ;���i��,�i..,�.�:..•`:'k!`�' •.°.�,,.]"� -'•:��`:-�i��
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<br /> This applfcatfon form must be completed in full and all required inf�rmatlon must be submi�ed.�� '"�'`".' 'r�4,
<br /> Incolnplet�applicatPons will be returned. (Please pNntJ
<br /> GEIdERAL INFORMATION:
<br /> Job SFte Addr�ess; a�p �
<br /> Will this be a Parade of Hom��RemodeFers Sh se Home or other Dlsplay Home? Yes •No
<br /> KYes,a speclal everd pe�/t/s req�/�d w�h py�ce Deparbnent end Clfy Counc!!app�ova/60 days pr��to tAe even� 5hulHe 6us senm�e wlll ee
<br /> iequh�+d unlesa epp/lcant der�onstr�tes sufPJc%nt orrsr7e pe►�Ing/s sva,7ebte. IVon-penn�l evernta wlll»ot be�Itawed ��
<br /> C�fdTRA,CTOR/�4PP4IC�AIT.INFORMA170 :
<br /> �Name: � 1-aA�t�oa �, -
<br /> State License# � 30
<br /> Lead Certification Number; �Pi�tion Date: 3..3 )-a�a�
<br /> T � 3'O S _ Expiration Date: ro- ��,_ �1 S
<br /> fl�r rtrork on homea tifat wera consVucted pdor co 1978
<br /> Phone: 5�a. gg_ _ (office) � � a �
<br /> Mailing Address: � E _ (cell)
<br /> Contact Person: � a � Ap lic2nt Ps: CCon r ~ + �p� g ��'
<br /> Emeil and/or Fax: P t a Homeowner �ou+��•v�@�
<br /> r
<br /> PROPERTY OWNER INFORMATIDN:
<br /> Name: ��u e.�
<br /> Phone(day); g��-g�� �
<br /> Address: ��,y�� �
<br /> �mail and/or Fex ���' 21P�
<br /> PRGJECT 1NFORMATION:
<br /> Type of Projec�
<br /> Any earth movem�nt ma re ui�
<br /> ❑Door�s) ❑Remcdel ❑Flre Damage �C1�b revPew&permlb
<br /> �R��,�p�H �Rep��� Minneh�ha Creek Watershed Dlstrict(MCWD)
<br /> ❑Storm Demage 18202 Mlnnetonka Blvd
<br /> ❑Re-roo�F,cedar ❑RestoraUon ❑Wat�r Damage Deephaven,MN 56391
<br /> ❑Re-roof,other(�pec(fy) ❑Siding ❑O�er:(speoi Phone: 952-471-0590
<br /> '�1 Fa�e 952-471-D88Z
<br /> ❑Windoav(s) �nr,minne ahacreek o�g
<br /> Overall ProJect Desc�i tlon:
<br /> Estlmateal Co�tructt n Yalu�t on of ProJec�t excl�ding a1 nd�$4�
<br /> APPLICANT ACKNOWLEDC�EMENT:
<br /> • Agre�s to provide all inFormation required or requested by the Building Department; •
<br /> • Certifies that the Informatlon supplisd is true and correct tv tha best of his/her knowledge, The appllasr�recognizes�h�t they
<br /> era solely responsible for submltting a cnmplete applice�on being aware that upon failur�to do so,the staff has no elternative
<br /> but to reject it until It is complete;
<br /> � Some or all of the int'ormetlon that you are asked to provide on this appllc�tion is classified by 3tate lew as elther prlvate or
<br /> canfidenbal, Private d�ta ►s information whic� generally cannot be given to the puhGc but can be give�to the sub�ect of the
<br /> data. Conflder�ial data Is informatlon wh�ch gene�tly cennot be given ta either the public or the subJect of the da�a, Our
<br /> pu�pose and intended use of this informa�on is to annually upda�e our records�nd records of other gcvarnrnental agenaes
<br /> uired b law, f ou�fuse to eu I the inform�tion,tl�e� Ilcation ma not be issued,
<br /> Appllcant's Signature: ` Date: _�'alv—
<br /> 1.8st Updpted: 08-09-2011 �
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