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<br /> r�t� of Orono � 3� c�3 �
<br /> Building Permit Application for Maintenance / Renovation �
<br /> {windows, doors, sidin , re-roof, etc.j `
<br /> O Mailr O Box 66 PP.tmi[rulmbef: Q —(7
<br /> � �� Crystal Bay,MN 55323-Q066 Date receiveci� ``���_2!- _
<br /> ��0 -� Q"';�.
<br /> a �,�<_ __ �1
<br /> .' _ a,�; Streel Address: Recerved by:
<br /> \\�'�.t M;�, G.`�/%` 2750 Kepey Parkway Plan review fee:
<br /> � Orono,MN 55356
<br /> ytLiggp�'4�%'
<br /> _—._ �/�
<br /> Total Fee: �i'� '� D
<br /> Mairt: 952-24g-4600 Fax: 952-249-4616 .�,,i�.+r�i�1rc�r�i�ri���u�,
<br /> _ --------
<br /> This apptication form must be completed in full and all required information must be submitted.
<br /> Incomplete applicati�s will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: 7�// j�i�c-:��r/ �/J• ./!!
<br /> WiH this be a Parade of Homes, Remodelers Showcase Home or other Display Home7 Yes o
<br /> 1l�nes,a speria/event permit is required with Paice departmPnt and Crty Cow�cd appraval 60 days priar to the ewenl. Shuttle bus serv6ce wifl be
<br /> required urdess app/icant demonstrates sulfi�ient on-site parktix�is available. Non-permilled eva?+�s wN/nol be a!lowerl.
<br /> CONTRACTOR!APPUCANT INFORMATION:
<br /> Name: f.r.��f Z /�.< �J,--,.-G �-,.-Tt'�2
<br /> State License#� �C�3l v yU Expiration Date: 3 �i ,p;��
<br /> Lead Certification Number: y-�7` _ �7p 7u - / Expiration Da[e: , �j ,z�,;5--�
<br /> (for w�ork on ltomes tl�at were corrstnicted priar ro 197E
<br /> Phone: 7 c 3 - y�g-GG'o � (o�ce) 6�1- -- ��G -�"so� (cell)
<br /> Mailing Address: /�7%o j�,,�,� rr- Ci�i y,.,e..�,� ZIP: S�y��
<br /> Contact Person: ,�;,,.T y ��«fir�„�,�,� Appticant is�� Contra�/ Homeowner �c.a.a,y
<br /> Email and/or Fax: �-�.<<FH�<-�.��c �,�,��.-..c .���-�,�..--��<-��-,z.. . �r-�---
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ��'� S�i��'�Tz f
<br /> Phone (day}: 7�s -��S� -ry�>S 3
<br /> Address: �yy ,�,.�«,,. �,� ,� City: Go.,�.a l,.�-i�f ZIP: s'S3S�
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Project: My earth movement may require
<br /> ❑Door(s) ❑Remodel ❑Fire Damage ��review&permns:
<br /> Minnehaha Creek Watershed Disuict(MCWD)
<br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage 18202 Mirnietonka 8ivd
<br /> ❑Re-root,cedar ❑Restoration ❑Water Damage �P�veri,MN 55391
<br /> Phone: 452-471-0590
<br /> ❑ Re•roof,other(speciry) ❑Si ' ❑Other:(specify) Fax: 952-471-0682
<br /> Window(s) www.minneh�h�r.rcc:k.orq
<br /> Overali Project Description:���-�•� �;,Q���ir.r r /�l i w;oF �l,z�3w;,�i �µr-�-�T �Cc s-�-�f s�tf
<br /> Estimated Consiruction Valuation of Project(excluding land) S '7'�Uv, c�� v � ���f"'"'�a S'
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department;
<br /> • Certifies that[he informalion supplied is true and correct to ihe besc of his/her knowledge. The applicar►t recognizes that they
<br /> are solely responsible for submitting a camplete application being aware thai upon fa�lure to do so, the statf has no altemative
<br /> but to reject it until it is complete;
<br /> • Some or all of the intarmauon that you are asked to provide on this a�lication is classified by State law as either private or
<br /> confidential. Private data is information which generaNy cannot be given to the pubNc but can be given to the wbject of[he
<br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our
<br /> purpose and irne�ed use of this infomiation is to annuatly update o�x rezords and records of otMer governmental agencies
<br /> re ufred b law. If ou refuse[o su I the information the a ication ma not be issued.
<br /> ApplicanYs 5ignature: ,,� Date: ��/`� �� Z
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<br /> �asc updaced: oa-os-zoi�
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