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Oct 05 2012 12: 21PM Herkshire Home Solutions 763-432-9854 p. l
<br /> , City of Orono
<br /> Bu�lding Permit Application for Maintenance 1 Renovation
<br /> (wlndows, doors, siding, re-roof, etc.)
<br /> h4elUng�Addr�ss: ��: ;�-� "' �: ,;;.: ;.� , .
<br /> �.►�.� P0 8ox A6 Permlf:nu:mb'ei':', ":' s� .
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<br /> Q Cry�tal 8ay, MN 66323-0066 : ...::`.�. : .+�::.,,,�:. ,.. , '..,+,. ;I
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<br /> � Date!r���iv���: ,,,:, ��
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<br /> � � Street Addiess; ..Rec;eiv�p'd.by.;,•::•,�;,;`�;,,f:=1;.�: ' Ni;'` '�..;
<br /> 27b0 Kelley Parkway Ip�len;revlew�f�q,::''``'
<br /> '�� ��a�' Orono, MN 55356 :_�
<br /> Meln: 952-248-4600 Fax; 952-249-4616 www,�i.orono.mn,us Tbt�1'Fe,�:;��-�_,`:'':�""`
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<br /> Thls applicatlan form must be completad In full and ell required Informatlon must be 6ubmitted.
<br /> Incomplete a�ppllcatlons wlll be returned. (Please print)
<br /> GENERA� INFORMATION:
<br /> Job 81te Addros�; 2 S�
<br /> Will thls be e Pprede of Homes, Remodel Showcate Nome vr othe�Dlaplay Home? Yes Wo
<br /> ll yee,a speclel evenf pwmlf/a required wlth Poliae Department end Clty Councl/approve/00 deys p�ior tv�he event. Shuttle bua se ' wlll be
<br /> required unless eppll�nr demonsfr�t�s suh9clenf on-sito perking is�va!leb/e. Non-permlttad events wi!!not be allowad.
<br /> COhITRACTOR/APPLICANT INF RMATION:
<br /> Name: � �b ����3
<br /> State Licen6e# G 2 Expiratlon Dete: ��c,�
<br /> Lead Certificatlon Number� T - -l Explration Date: �
<br /> (Ioi w�ork on homes that wsre conshvct�e prioi to 9978
<br /> Phone; 7��, �,�j'�Z- � S� (offlce? (0l2-2'Z? -I-� �-�3 (cell)
<br /> Mailing Addresa; � � � �Ity; �, ZIP: �-�-c.�47 _
<br /> Contact Person: ��� �f� � Applicant Is: Con rac or / Homeawner �circ�•on.�
<br /> �mail and/or Fax; ��- � �,5 ��,,,� �^�, 2 �
<br /> PROPERTY OWNER INFORMATION;
<br /> Name; �,,, ��,�,��
<br /> Phone(day); c. _ �� '
<br /> Addreas: _ �z2 � '�,�s;�_ City: D,��,� ZIP• �535'�
<br /> Emall end/or F�x �'i"f-` ' � —�
<br /> PROJECT INFORMATION:
<br /> Typa of ProJect: ' Any earth movement rt�ay requlrs
<br /> ❑�oor(s} ❑Remodel MCWti revisw 8►
<br /> ❑�Ira Damage permlt�:
<br /> �,Re-roof, asphalt ❑Repalr Minneh�ha Creek Watershed Distrlct(MCWD)
<br /> �3torm Dama9� 18202 Mlnnetanke 81vd
<br /> ❑Re-rooi, cedar ❑ Reatoratlon ❑Waier Damage Deephaven, MN 55391
<br /> ❑Re-roof, other(tpoerry) ❑Slding ❑ Other: (s ecif Phone; 662-471-Ob90
<br /> p v) Fez: 952•471-08e2
<br /> �Wlndow(s) • � aha ,or
<br /> Overall Prv oct DesCrl lon: fL-�w
<br /> Estlmated Conatructlon Valuaflon of P�o ect(excludin land $
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees ta provlde ell InFormation required or requeated by the BufldinQ Departmerit;
<br /> • Cerlliles Ihat the Intormatlon eupplled le true and correct to the beat of hislher knowledge, The eppllcant recopnaea th�t they
<br /> are eolely responslble for suhmitting a complete applice�on being awere that upon fellure to do eo, the staf�has no elternetive
<br /> but to re�ect it untll It Is complete;
<br /> • Some or ell of the Int�rmatlon that you er'8 asked to provlde on thia eppllcation Is Gas�lfied by Stete law ee elther prlvate or
<br /> confidentlel. Private deta is Informelion whlch penerelly cannot be Qlven to the publlC but cen be eiven to the eubJect of the
<br /> data. Confidentlal data Is lnfo�metfon which gane►ally connot be glven to efther the public or the subJect af ihe dete_ Our
<br /> purpo6e and intended use of thls information la to annuelly update our recorda and recorde of other governmental agenclea
<br /> re ulred b law. If ou re�se to eu 1 the Iniormatlon the a Ilcatian ma not be leeued.
<br /> Applicent's Signeture; bate: (o � 2
<br /> Loot Updeted; 08-0�-2011 �� 1 1 ` , � � �
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