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AUG-26-2011 07:19 From: 6785736615 To:19522494616 Pa9e:z�z <br /> . , . <br /> City of Orono <br /> 6uilding Perunit Application for Maintenance / Renovation <br /> Qwindows� doors, siding, �e-roof, etc.) <br /> MelJing Add�ss: permll number �D/�-d4�J`�-3 <br /> O.�D,�.O PO 6ox 66 <br /> Crystsl Bay, MN 55323-0066 Date received: �� !/ <br /> St�et Address: ReCeiv9d by: <br /> 2750 Kelley Parkway Plan review(ee: <br /> ���x�� Orono,MN 55356 �/� <br /> T�I Fee: '7'07��'O <br /> Main: 952-249�600 Fex: 852-249�616 www,ci.orono.mn,us <br /> This application f�orm must be completed in full and ell required infortnetion must be submitted. <br /> INcomplete applications will De returned. (P/ease print) <br /> GENERAL IIdFORMATION: I�� �ri 5�b rl, �I•r• <br /> Job Site Addtess: <br /> Will this be a Parade of Homes.Remodelers Showcaee Home or other�isplay Home? Yes No <br /> If ye�a speaal event p�►m�f is requi►od with Police Department end City Council appmval 60 days prior ro(he e►rent. Shuttle bus seivice wiU tre <br /> required unless applicanf demonstrates sufAcient onsite parkNrg is avallaDlB. Non�eimiltea events w;ll not be allowed. <br /> CONTRACTOR/APPLIC NT INFORMATION: 1 <br /> fdame: �iv�o n C•rS�Yt?GT�d^ <br /> State License# Zp �C'6 Expiration Date: 3 12 <br /> Lead Certification Numb�r: /yJ�T S?3 StS� 1 Expiration Oate: <br /> (for wc�on homes that were consbvcted p�or to 19�8 <br /> Phone: (��2. �6��- 7DD0 (office) (cell) <br /> Mailing Address: 1 Z�j�b �;�.�� . esQ �V Ci : urhSV� �•C ZIF: �"j s"7✓ 3� <br /> Contact Persan: �v�'r, w,,,,� AppliCant is: tractor Homeowner �ci�i.o�a� <br /> Email and/or Fax: e�,;�, �;,�,� a�,,,g �en. Co M''� <br /> PROPERTY OWNER INFORMA N: <br /> Name: �l o In� �+.r��'� L� S S�i <br /> Phone(day): (,��— 9 -� b 2Z 3� <br /> Address: �b O�S .Fon i%. Clty: �brt o ZIP: <br /> Email and/o�Fax <br /> PR�JECT INFOf2MAT10N: <br /> Type cF ProJect: Any eaKh movement may require <br /> ❑Door(s) ❑Remodel 0 Fire Damage MCWD revlew B�permits: <br /> Minnehaha Creek Watershed Dislr9ct(MCWD) <br /> '�e-roo(,asphalt ❑Rep3ir ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Restorafion ❑Water Damage Deephaven,MN 55391 <br /> Phone: 95Z-a71-0580 <br /> ❑Re-roof,othe�(sp�clfy) ❑Siding ❑Qther:(speC�fy) Fax: 952�171-0682 <br /> ❑wndow(s) <br /> www.minn�hahacreek.orq <br /> Overall Pro ect Descrlptlon: .Car �µ�# ✓-C �/oo <br /> Estlm�ted Constructlon Valuatlon of Project(excluding land) $ ��T 00'� <br /> APPLICAPIT ACKNOWLEDGEMENT: <br /> . Agrees m provide all Informa�"on required or requested by the Building Deparbnent; <br /> • CeRifies that the information supplied is true and correct to fhe best of his/her knowledge. The appllcanl recogniaes that tAey <br /> are solely responsible for submilting s onmplete appliration being aware that upon Failure to do so, the staff has no allemative <br /> bu!lo reJecf if until it is complote; <br /> • 3ome or all of the Info►maliom that you are asked to provide on Ihis application is classified by State law as either private or <br /> confidential. Private data is information which generaliy cannot be given to the public but can be given to the subject of Ihe <br /> data. ConfidenUal dala is iniormaGon which seneralty cannot be given to either lhe public or the subject oi the data. Our <br /> purpose end inlended use o1 I�is informalion ia to annually update our records and records oi other govemment�l Sgenues <br /> re uired b law_ It ou refuse to su I the information,the a lication ma nol be issued. <br /> ApplicanYs SignaturB: Date: � Z� Za 1 <br />