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, � City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, sidin , re-roof, etc.y <br /> �O� MailiPO Box 68 . Pemllt pumber: � Of o2 � �� 5� <br /> 0 � Cryatal Bay, M N 55323-0066 Date recelved:. —2� `�� <br /> Street Addresa; Recelved by; �J <br /> � 2750 Kelley Perkwey pf�n�review fiee; <br /> ����N Orono, MN 53356 <br /> Total Fee: �( �,gj� <br /> Mairt: 952-2�9-4600 F�t; 952-249-4616 mt�m.ci.orono.mn.us r•� <br /> Thls applicatlon to�rn must be wrnpleted in full end ell required informativn must be submitted. <br /> Incomplete appllcatlons wlll be returned.. (Please print) <br /> GENERAL INFa,RMATION: <br /> Job Slte Addresa: 3��_Gr� (�c��/ ��i <br /> WIII thls be a Parade of Homes, Remodelers Showcese Homa or other Dlsplay Home4 YeB No <br /> If yee,e specieU�vent permit is iequirod with Pofice Depertment an0 Ciy Counci!epprvval 60 deys prior tv the event 3huttle bus service will be <br /> r�qu�red unless applioeni demonstrates aufficlent on-shte perkln�la evAllabls. Nan-perm/tled eventa wlll not be al/owed. <br /> CONTRACTOR/APPLICA T IN ORM TION: <br /> Name: G,/c^;�p� �'�r�(,�j <br /> State License# F�cplratlon Date: j �� <br /> Lead Certlflcation Number, � , � ��h ,( Expiration Date; <br /> (for work on h�mea th�t were conatructed prlor to 49T8 <br /> phone; , �, ,p� (offlce) (cell) <br /> MaIIIngAddress: ��� � � City� •�J'IP: U <br /> Contact Person: , ,Applicant is; ontract / Homeowner � (C�ro�o Ono� <br /> Email andlor Fax: ,� w� r,.,i„ { , ,�_ � � � _ _ •� q� <br /> PROPERTY OWNER INFORMAT�N; <br /> Name: 1�1, ,�.• ^-�� �S <br /> Phone (day): �(�_-_. ���- � j� / <br /> �_77/� ��_S, � <br /> Address, !� f�J City; �•,,� l�,. �.G ZIP: �,�,��� <br /> Email and/or Fax <br /> PROJECT INF RMATION; <br /> Type oT ProJect; Any earth movement may requlre <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD revlew&perml�s: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,Ssphalt � Repair ❑3torm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Resto�atlon ❑Water Darnage beepheven, MN 55881 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(�peclty► ❑ Sldlnp ❑ Other: (specify) Fax; 952-471-0682 <br /> �Wlndow(�) www.mi nnehahacreek.ora <br /> Overall Pro)ect eacrlptlon: '.�,� �,U rn t�S in P�f'�S• �' G�� <br /> Estlmated Ccnstructlon Valuatlon of Pr ct excludln lend S '�� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all Informatlon required or requesied by the Buildina Department; <br /> . Cerllfles that tha Informetlon supplled Is trua and correct to the best of hls/har knowledge. The applicant recognizes that they <br /> aro •olely�responelble for aubmliting e complete eppllcatlon being awaro ihet upon failuro ta do ao, the staff has no alternative <br /> bu!to reJept It untll It Is complete; <br /> � Some or all of the infvrmation thal you are asked to provide an this application is classified by State law as either private o1' <br /> confidenti8l. Private daia is informaiion which generally cannot ba given to the public but can be given to the subject of the <br /> data. Confidential data is inf�orm�tion which generelly cennot be piven to either tha public or the aubject of the date. Our <br /> purpose and intended use of this informetion is bo ennuelly updai� our records and records oi vth�r governrnental agencles <br /> re uired b law� If au refiuse io su I inform 'on,the a li iion ma not be issued, <br /> Appllcant's Slgnature: ~F� ' Date: ����"��- <br /> Lest Updated: 08-09•2011 <br /> T 'd S6�0 OLL TS9 pt.�o� mopuz� WdLT �OT ZTOZ ZO ��d <br />