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� Oc+:.12, 2012 9: 39AM No, 9702 P, 1 ' � ol�y��v I City of Orono i Building Permit Application for Maintenance / Renovation � (windows, doors, siding, re-roof, etc.) � Mailing Address: Permit number, 07+��' Q�' L� O�O�O Crystal Bay,MN 55323-Do66 Date received: ✓0�2��' I ;: . I a ,, Street Add/ess: Reoelved by: 3�, G�' 2750 Kelle Parkwa ' �R��o�,�+ Orono,MN 55356 Y y To„tal Fe �',/ :: . . .. 7� _ _�� e:..:..:. .. :. . Main_ 952-249�{600 Fax: 952-248-4616 www.ci.orono m� ' ' : :. � .. . � > This application form must be completed in full and all required information must be submitted. Incomplete applicatlons wlll be retumed. (Please print) GENERAL INFORMATION: C^, p 0 � e � � �2 ,� 2 � Job Slte Address: / Q ��- Nfill this be a Parade of Homes�Remodelers Showcase Nome or other Display Home7 Yes o N yea,a special event permit is required with Police Deparfinent and City Council approvel 60 days pric�to the event. Shuttle bus se►vice will0e , required unlesa epplicant demonstrstes su(ficient on-slte parfong is available. Non-permitted events will not be allowed CONTRACTOR/APPLICANT INFORMATION: Name: -s'c�h e,rz-��. Q R�,.P: State License# �C ,� 3 S 3 b q Expiration Date: 3 � Lead Certification Number: y�l�}-r_ � �3 "S- � Expiration Date: �j!f�� a,� (fvr work on omea that were constructed pNor to�976 � Phone: (office) (cell) Mailing Addres : o City: ZIP; Contact Person: (� c.�� Applicant is ontra o / Homeowner �c�tiie �a� Email and/or Fex: � �- � -a ��I � q d PROPERTY OWNER INFORMATION• I ` � Name: . �� fZa� ��ti� � W� �f S o „ Phone(day): � � • 3�Z— 5�., Address: _� � � � � � c�,.1�,�, � � �� City: L a-.� ca--O.n ZIP: .5.� 3's� Email and/or Fax � � � PROJECT INFORMATION: rype of Projecr Any eorth movement may roquire ❑Door(s) ❑Remodel ❑Fire Damage MCWD review 8�permfls: Minnehaha C�eek Watershed Distnct(MCWD) ❑ Re-roof, �sphalt ❑ Repair ❑Storm Damage 1B202 Minnetonka Blvd ❑Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven,MN 55391 Phone; 952-d71-o590 ❑Re-roof,other(spec�iy� ❑Siding ❑�ther: (specify) Fax: 952�71-0682 wvwo.minne hahacreek.orn [�1lfindow(s) Ovefall Project Descllptlon: �� �stimated Constructlon Valuation of P�oJect(excluding land) 3 j a (aa 5. � � APPLICANT ACKNOWLEDGEMENT: . Agrees to provide all information required or requested by the Building Department; � . Certifies that the information supplied is true and oorrect to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to reject it until it is complete; • Some or a►I of the infortnation that you are asked to provide on this application is classi6ed by State law as either private o� confidential. Private data is information which generally cannot be given to the publ;c but can be given to the subject of the data. Confidentiaf data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other govemmental agencies re uired b lew. If ou refuse to su I the information the a lication ma not be issued. � Applicsnt's Signature: �G�(� C�i--n. Date: �d '��. -'( ��_ � __..,_,a_,. ..............