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OC�-I�S-�"a12 21:07 FROM:TREBILFOUNDATION SYS 3205938720 T0:19522494616 P.2�3 <br /> � I - <br /> i�.1� -�—'� , S S��- <br /> � ��n-���.� �r...S l/ J.`�``� <br /> � Cifiy of Orono �� ����� r����� '��e <br /> Building P�rmit Application for Maintenance / Renovation '�a r`' -�6-' z <br /> (wlndows, doors, slding, re-roof, etc.) <br /> Mailing Address: p�rmiC number; o��/o�-�/U� <br /> I Og,O j�O PO Box 66 <br /> Cryatal Bay, MN�5323�0066 Data received: ���6�� <br /> � ' Str�et AddreSs. Rocolve.d by, <br /> G� 2750 Kelley P�ikwdy PI8r1 fCVlBw('eC: <br /> I � �.� Orono, MN 55356 � / <br /> ! �� Totel Pee; /,�� �L� <br /> Mein, 952-248�4600 Fax: 952-249-4616 www.cl,orono.mn,us Y 1 <br /> �� This application form must be completed in full and all required informetion must be submitted. <br /> Inoomplete appllc�klon�wlll ba retumod. (Plaasa p�nt) <br /> GENERA�INFORM4TION: <br /> JQb Slte Address: V� <br /> VI'lll thls be a Parade of Homes.Remodelers Showcasa Homs or other Dlsplay Home? Yes No <br /> � Nyat,a spedal e�renC pem►�Is ispuWd wRh Pollce Depa�trnent and C!!y Councll approva180 deys pibr to the ovsnt. Shuttb bu9 esMc+e wlll bs <br /> roqui�ed unless eppllcent demonstretes 8uflsc�ent orrslte parking.ls avaUabls. Non-pem►lftsd susnts wlll nof bs elbwed. <br /> CQN7RACTOR/APPLICANT INFORMAt10N: <br /> N�e' ��Q�.a�.T('�� �i����-i�r� ���n <br /> Spte �icense# b� y y.������ �— Exp�retion Dete: �_3 I� 1� <br /> L ed Certification Number. y��-_ , ,� a�q_ � Explration Dete: 3_ ��_���� <br /> ... <br /> (tw worfr on homos LhBt were consbuc[�ed prlor to 1878 <br /> P�one; ���_ ��� _ (o�ce) (ceU) <br /> MPiling Address: City: �� ZIP: �' <br /> CQntect Person: L�����Qp �a,a�� Applicsnt is: ra / Homeowner �c��i.o�.� <br /> Email end/or Fax: � rn�n � S1��P�r��ma v��� ,C��C't.1. ......�.�.� .�s�Q:�.��'i� — �7� <br /> { ` <br /> P�tOPERTY OWN6R INFORMATION: . <br /> N�me= _�P blo.�� �(Y1ron�l„�,� <br /> Phone(dey): 1 I„�-,�3\ " I 1�3 1 <br /> A�dreas: c�l`I D� E`�-hp a �,� ��ty� , r t�C� ZIP: a� '`�J 3 �, <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Ty�pe of ProJec� Any earth movement may raqulre <br /> [�Door(s) Q Remodel ❑Fira Demege MCWD re�vl�w b pertnite; <br /> Minnehahe Creek Watershed qistrict(MCWD) <br /> [�Re-roof,esphalt Rapair ❑SDorm Oamage 18202 Minne�tonka Blvd <br /> ❑Re�roof, ceda� ❑Resroradon ❑Weter pamage OBepheven, MN 55391 <br /> Phone: 852-471-059a <br /> [,�Re-roof, other(spac�y) ❑ 5iding ❑Other: (speciFy) Fex: 952-471-0662 <br /> � Q Window(s) �vu�nv,minnehahacreek.ora <br /> Overall Pro eet Descrl lon:Z ', � ; <br /> E�tlmatsd Constructlon Valuation of Pro ect(excludln land) S � 3 ` ��a� <br /> ARPLICANT ACKNOWLEDGEMENT: �1�� � �� ��� I n'���� <br /> • Agrees to provlde ell infonnetion required or requested by the Building DepBrtment; g�,��, <br /> • Certifies that tfia infoRnetion supplied is true and Co�reCt to the best of hlsR�er knowledge. Tho epplicant reoognl2es thet they <br /> ere solely respor�sible for submitting e C�mplete epplication being eware t�at upon failure to do so, the ateH hae no alt�ametive <br /> but to reJed ir until it ia complete; <br /> � SOme or all ot the infonnatlon that you ere asked to provide on thls applicaaon is daeelfled by Scate taw as either private or <br /> con6dential. Privete data is informetion which generally pnnot be given to the publlc but can ba given to the subject.of the <br /> data. Confiderrtiel data Is InfOmlatlon which genefally cannot be given to aither the public or the eubJect of the d�te. Our <br /> purpose end ir►tended use of titis infomlation is to annually update our remrds and records of other government8l egencies <br /> uired b law. if u rofu8a to su I the informetlon tne e Ilcatlom m �ot bo issuaC. <br /> Ap licant's Signature: L.�1,�. o OQ o . I,'� c n� � R��n� Date: I O _ <br /> L88 Updetad; 0&-09-2011 . <br />