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O <br /> � �� City of Orono <br /> Building �ermit Applicat�on for Maintenance 1 Renovation <br /> (windaws, doors, siding, re-raof, etc.) <br /> Mtr!!i»g Address' P�rmit number: <br /> a.�,Q�.O Pd Box�6 <br /> Crystal gay, MN 55323-0066 t�ate received: <br /> '' '� Received by: <br /> � � ^;�„ a, Street Address= <br /> �� �' 2750 Kelley,Parkway Plan review fie�: <br /> �{.���I;���' Orono, MN 55356 <br /> Total Fe�_ <br /> Main: 952-249-4600 �9x' 952-249�61fi www.ci.orono.n�n.us <br /> This appfication form must be completied in full and all required information must be submitted. <br /> lncornpiete applications w111 b� returned. (Please print) <br /> GENERAL INFORMATION: �02 b ��h� �Q� <br /> Job Site Address: J <br /> Will this be a Parade of Homes, Rempdelers Showcase Mome or other Dfsplay Home? ❑Yes No <br /> If yes,a specia!event permlt/s requlred wlth Police Departm�nt and Gity CpuncU approval 60 days pRor to thy event Shultle bus service rvill be <br /> required unless epplicant demonstrates sufflclent on-site parKing is aveUable. Non-permitted events w1l1 npt be a!lowed. <br /> CONTRAC70R/APPL[CANT INFORMATION: <br /> Name: �-e,n�a.� 3y �qr�d.erse,r� <br /> State License# "$G\��`�S3 Expiration Date' '?�(3� <br /> Lead Ce�tification Number� �j —r�. ��ag� — Expiration Date: y Jts � <br /> (for work on homes that wer�a�canstruci�ed prior ta 1978 <br /> Phone: (a51- a(py-�10$$- �t.�Ah (office) (Ce11} <br /> Mailing Address' �qa� C,O. "j�d '�" wey� City: ; � ZIP: $S(l�a , <br /> Cantact Person: Applicant is: n rae r / Womeowner ic�rcie one) <br /> Email and/or Fax: � �� ^ <br /> PROPERTY OWN�R INFORMATION: 1` <br /> Name: �G�'h�,S � ,1 C2Q.,{�- <br /> Phone(day): `1 �2� —6W� _� <br /> Address: �D3tj�Vq,�,, City: ZIP� <br /> Emaii andlor Fax <br /> PROJECT ItNFORMATION: <br /> Type af ProJect: Any earth movement may requir� <br /> MGWD review 8 permits: <br /> ❑ Roor(s) ❑ Remodel ❑ Fire Damage Minnehaha Creek Watershed District(MCWQ) <br /> ❑ Re-roof,asphalt � ❑ Repair �]S#orm Damage 18202 Minnetonka Slvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Ra-roof,other(spsclfy) ❑Siding �Okher: (specify) Fax' 952-471-0682 <br /> ❑Window(s) www,minnehahacreek:arq <br /> � <br /> Overall Project Description:�{j�p (O , �� '� U �i'Z <br /> Estimated Construction Valuation of Project(exciuding land $ � - <br /> � ;�APPI.lCANT ACKNOWLEDGEMENT: <br /> . Agrees to provlde aIl Informat.ion required ar request�d by the Build',ng Department; � <br /> . Cortifies thaC the information supplied is true and correct ia the best of his/her knowiedge. The applicant r�cogni�es that they <br /> are solely responstbie for submitting a complete appfication being aware that upon faiiure to do so, the stafF has no alternative <br /> but to reject it until it is complete; <br /> • Some or aIl of the information that you are asked to provide on this appfication is cEassifsed by State law as eith0r priv�t� or <br /> oonfidential. Private data is inivrmation which generally cannvt be given to the publlc but can be given to the subject ot the <br /> data. Confldential data is infarmation which generally cannot be given to either the public or the subj�ict of tl-�e data. Our <br /> purpos� and intQnded use of th1S infprmatiqn is to annuaily update our records and records of other governmentaE ageneies <br /> re uired b 1aw- If qu refuss tp su 1 the information the a lication ma not be issued, <br /> Apolicant'sSianature: �/' �✓ bate_ �� ��1 �� <br />