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AUG/29/2011/MON 09: 45 AM FAX No, 9527367545 P, 002
<br /> City of Qrona
<br /> Building Permi� Application for Maintenance I Renovation
<br /> (windows, doors, siding, re-roof, etc.)
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<br /> � PO Box 66 ;:Fsrmitlne�iiber:r:::;;1!:!:,.:�,-,� �,.; ii ��'�i �i��':'•. :
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<br /> � Crystal Bay,MN 55323-0066 (����rQ�Q'y��; � �
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<br /> \� �� Orono, MN 55356 ', , ;
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<br /> Main: 852-249-4600 Fax: �52-249-4616 www.ci.orono.mn_us :;:�'':�' �I�r �;���'�:I���+��� ��.`�.����� ��� � �� :�
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<br /> This application form must be compl�Dad in full and all required information must be submitted.
<br /> Incomplete applications will be r'eturned. (Please pr�nt)
<br /> GENERAL INFORIVIATION•
<br /> Job Site Address: � r C,� � : �� � ,
<br /> Will this be a Parade o�Homes, Retno e ers Showcase Hotne or other Display ome? Yes o
<br /> I(yes,a speclal evant pennit is required with Police Department and City Council approval8a days p�lo�lo the event, Shuttle bus sslvJce will be
<br /> requlred un/ess applicant ciemonsfrates su�cient on-site parking is available. Non-pemtitted evsnts wlll not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATI�N:
<br /> Name: �C b V� t--l� C�
<br /> State License# Expiration Date: 2� � � 3
<br /> Lead Certification Number: �--j_ l U� r� Expiration Date: •'� '�'� �
<br /> (tar work on homes that were constructed prlor to 9978
<br /> Phone: �— � (office) ��� 2- � �,� (cell)
<br /> Mailing Address: �,�,, Cit � ZIP:
<br /> Contact Person: Applican�is: o ractor / Homeowner (c4-c!e one)
<br /> Email and/or Fau: ' � r Q i/'� , (
<br /> pROP�RIY OWNE INF CtMAT10N:
<br /> � Name: �� --9_' �-��V \'���
<br /> Phone (day):
<br /> �ddress: L�.�r�l/L S )1( l r JL Y�.� City: ZIP:
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> [] Door(s) ❑Remodel ❑ Fire Damage NICWD review&permits:
<br /> Minnehaha Creek Watershed Disfrict(MCWD)
<br /> �Re-roof,asphalt ❑1Zepair ❑Storm Damage 18202 Mlhnetonka Blvd
<br /> ❑ Re-roof,cedar �]}Zesto�ation ❑Water Damage Deephaven, MN 55391
<br /> Phone: 952-471-o59a
<br /> ❑ Re-roof,other(specity) ❑Siding ❑Other:(specify) �aX; 952-471-0662
<br /> ❑Window(s) www.minnehahacreek.ar�a
<br /> Overall Project Description:
<br /> Estimated Gonstruction Valuation of Praject(excluding land) $ � �� �� � —
<br /> APPLICANT ACKNOWLEOGEMENT:
<br /> • Agrees to provide all infnrmetion required or rEquested by the Buflding beparCment
<br /> � C�rtifies that the information supplied is true and correct to the best of hislhe� knowiedge. The applicant re�ognizes that they
<br /> are solely responsible for submitting a complete applicaEioh being aware that upon failure to do so,the staff has no altemetive
<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 either privafe or
<br /> cor�fldehtial. Private data is information which general(y cannot be given to the public but can be given to the subJecf of the
<br /> data_ Confidential data is informatioh which generally cannot be given to either the public or the subject aF the data. Our
<br /> purpose and intended use of this information is to annually update our records and records af orther'govetnmental agencies
<br /> re uired b law, li ou refuse to su I the informati the� Ifcallon ma nol be fssued.
<br /> ApplicanYs Sianature= Date: �� Z�- 2 a /�
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