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Oct, 8, 2012 9: AM R, A, UNGERMAN CONST. 6128252901 No. 9064 P. 1 <br /> � ���� � Cit of Orono <br /> 1 � I y <br /> Building Permit Application for Maintenance / Renovation <br /> � (windows, doors, siding� re-roof, etc.) <br /> � ' Mailing Address: � <br /> .�,0� PO Box 66 Permit number. - <br /> � Q Crystal Bay,MN 55323-0066 Date received: /O —�/ <br /> , � , �. Sireet Address: Received by: <br /> ��' 275o Kelley Parkway Plan review fe : <br /> �yyk,Eg o�,� Orono, MN 55356 <br /> Total Fee: /�P��� <br /> Main: 952-248�i600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed ln full and all required information must be submitted. <br /> Incompfete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> ,Job Site Address: Q� l� � Ej - �rc� i�v�� �,4 <br /> '� WIII this be a Parade of liomes,Remodelers 3howcase Flome or other Dlaplay Home? Yes No <br /> � 1l yes,a special event permit is required with Police Depadment and City Counci!approval 60 days pdor to(he event. Shutt/e bus servlce will bs � <br /> required unless applicant demonstrates sufficient on-site parking is avallable. Non peimltied events will not be el/ow�ed. �V � <br /> � CONTRACTOR/APP ICANT INFORMATION: ���1 �C��� <br /> Name: 6 .uST (�LG �1 D ��, " <br /> State�icense# G �Z,3q Lxpiration Date: 3 3/ Za 3 <br /> Lead Certification Number: tijN_ 5C�33�� Expiration Date: 7 7�j <br /> (fnr work on homes that weie constructe prior to 1978 /' �j �T <br /> Phone; �'/Z- $Z 5- ��d (office) 6 r�'p�0 p��OTv� (cell) <br /> Mailing Address� r/ ,�j�� City: „�,s ZIP; c// <br /> Contact Person: �,,,�, r,/�,6E�,�,� Applicant is: ac / Homeowner (Clrclo Onv) <br /> Email and/or Fax: �� Z.,gZ��qp/ <br /> PRaPERTY OWNER INFORMATION: <br /> Name: � ,B /IiI,S <br /> Phone(day): � . (Q- [J <br /> Address: '�O3 rG(S'ni�� -�1a Z ��tY��Xl.£Gt�odc- ZIP: S"f,33/ <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits: <br /> ❑�Door(s) ❑Ramodel ❑Fire Oamage Minnehaha Greek Watershed District(MGWD) <br /> Ly1 Re-roof,asphalt ❑Repair ❑Storm Damage 18202 Mlnnetonka Blvd <br /> ❑Re-roof,cedar ❑ Restoretion ❑Water Damage Deephaven,MN 55391 <br /> Phone� 952-471-0590 <br /> ❑Re-roof, ot�her(spaclfy) ❑ Siding ❑Other.(specify) Fax: 952-471-0662 <br />� ❑Window(s) <br /> www.minnehahecreek.orsl <br />� Overall Pro)vct Desc�lptlon; <br /> Estlmated C,onstruction Valuatlon of Project(excluding land) $ l/�i�J. <br /> I <br /> APpLICANT ACKNOWLEDGEMENT; <br /> . Agrees to provide all inFormation required or requested by the Building Depariment; <br /> . CertiFtes that the infortnation supplled Is true and correcl to the best of hls/her knowledge. The applicant recognizes that they <br /> ara solely responsible for submitting a complete application being awara that upon failure to do so, the staff has�o alternative <br /> but to reject it until it is complete; <br /> • Some or all of the inFormation that you are asked to provide on this application is classified by State law as eilher private or <br /> confidential, Private data is information which generally cannot be given to the public but can be given to the subject of the <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 intended use of this in i n is to nnually update our records and records of other governmental agencies <br /> re uired b lew. If ou refuse t I inF n the a licati ma not be issued. <br /> Appllcant's Signature: Date: ���Q(��fC ��lZ <br />