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� • <br /> Gity of arono <br /> Building Permit Appiic�tion for Maintenance / Renovation <br /> , �windows, doors, siding, re-roof, etc.) <br /> i Mai/ing Address: PermiC number: ����`"O p3d l <br /> O•�T„d,�a i PO Box 66 `� <br /> � Crystal eay, MN 55323-0086 Date received: - �-� 7 <br /> � I � <br /> � � �, SfreetAddress: Receivsd by: <br /> "� 2�50 Kelley Parkway Pian revfew fee: <br /> �.������� � Orono, MN 55356 , /// (/' <br /> Total Fee: p? Y `�.. Za <br /> Main: 952-249-�6(}OI Fax: 952-249�616 www.ci.orono.mn.us <br /> This appliCatian form must be completed in fufl and all required information must be submitted. <br /> ncomplete applications witl be returned. (Please prrnf) <br /> GENERAL INFORMATION: � � a ��-m�� �, !�„ <br /> Job Site Address: �1,� . <br /> Will thfs be a Parade of Homes, Remodefers Shawcase Home or other Display Home? Yes ❑ No <br /> I'f yes,a specis!evenf permit is repuired wlth Pollce Depa�tm'ent and Cify Counc!!approval 60 days prior to the event. ShutfJe bu8 Serv/ce wiN 6e <br /> requlrad unless appl�cant demonstrate8 sUfilclem on,site parking is avail�bla. Non-permitted eVent9 wlll not tre allowed. <br /> CONTRACTOR/APPLICANT INF�RMATIQN: <br /> Name: 1��1�.Wa.\ `�y'Av��.�(Ser� <br /> State License# '$G 1309$3 � Expiration Date: 3(3� <br /> Lead Cerfification Number (V�"("_. ��a$� -�� �xpiratipn Date: �{l�4 <br /> (for work on homes that were conafructed nrior to i978 <br /> Phone� (n��.- c�(�l�-�(.O$'�'' ��An (otfice) (celf} <br /> M�iling Address: �ctap �� �� �e�,} City:'�,pPc� ; � Z��= SS Il� <br /> Contact Person: Applicant is: ontra / Homeowner (Circle One) <br /> Email and/or F�x= <br /> PROP�R7Y OWNER INFORMATION: <br /> Name: 1(3 C�� �. <br /> Phone (day): �$;�, <br /> Ada�ess: 9�� � N�1-�bl p� c�ty: ziw: <br /> Email and/ar Fax <br /> PROJECT INF�RMATION: <br /> Type of ProJect: Any�arth movement may require <br /> ❑ Doar(s) Q Remodel []Fire Damage MCWD revtew&pe.mits: <br /> Minnehaha Greek Watershed Distrfct{MCWD} <br /> �R�rQaf, asphalt ❑ Repair ❑Storm D�m�ge 182Q2 Minnetonka Blvd <br /> ❑Fte-roof,cedar ❑ Rastoration �Water Damage Q�ephaven, MN 55391 <br /> Phone: 952�71-0590 <br /> []Re-roof,oth�r(specify) ❑Siding ❑OIher. (speci�y) Fax' 952-471-0682 <br /> www.minnehahacreek.o[q <br /> [�Window(s) ,�„" , <br /> Overall Project Description: 1D�G W;+t�0 e,U c.�;o dar.,�S C.t1),n ..P�'�C�Sfi <br /> Estimated Construction Valuation of Project(excludfng land) $ / — i <br /> APPLIGANT ACKNOWLE�GEMENT: <br /> . Agrees to provlde aU information requirad or requested by the Building Department: <br /> • Gerti�ies that the information supplied is true and correct to the b�st of his/her knowledge. rhe applicant recogniaes that thay <br /> sre solely responsible for submitting a complete applicatian being aware that upon failure to do so, the staff has no alEemative <br /> but to reject it until it is completo; <br /> • Some or all of the infarmation that you are asker! ta provide on this application is classified by State law as either private or <br /> confidential. Private data is iniormation which generally cannot be given to the public but can �e given to the subject oF the <br /> data. Confidential da4a is informsUan which gen�raliy cannot be given to eltfier the pubtic or the subject of the data. Our <br /> purpose and intended use of this lnformation is to annuaily update our records and records of other govemmental agencies <br /> re uired b law. If ou refuse to su 1 the infiormation Che a lication ma not be issued, _r <br /> AQolicanYs Sianature: C�� Daie: ���r� �1 � <br />