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, � City of Orano <br /> Building Permit A,pplication for Maintenan�e I Renovatiorr <br /> (windows, doors, siding, re-roof, etc.} <br /> Mafling Address: p��m�t number p70/ �—�D�� <br /> �,�Q�Q Po aox ss �': a _ <br /> Crystat Bay,MN 55323-0066 Date received: <br /> Recelved by' <br /> � ,r Street Add�ss: <br /> � ' � 2750 KeEley Parkway Plan revi�w fiee: <br /> L��;sao�G Orono,MN 55356 , /'� . /� <br /> 7ota1 Fee: �f <br /> Main: 9�2-249-d600 Fax: 952-249-4616 ci.aro mn.us <br /> This applfcation form must be completed In fuli and alf required Info�rnation rnust be submitted. <br /> Incomplete appllcafsons wi11 be returned. (Pteas�print) <br /> GEN�RAL fNFC?RMATION: 4G} � �� .�o t 1'1eSs �Q►I(t� ►�C.�� • .r <br /> Job Site Address: j � <br /> Wilf this be a Ps�ade of Homes, Remodelers Showcase Horr��or other Display Home? Yes Na <br /> 1!yes,a Specia!event pemtft�s requir�d wrth Po11Ce Departmenf and City Council approva160 ddys Pnor to the event. ShUttle bus seN1G9 wBf b9 <br /> rigquiried unless applFCant demCnstrates sUfflcient Onsife parking is aVallable. lVon permltted events w�Jl not be alJowed. <br /> CONTRACT�R/APPLICANT INF�RMATION: <br /> Name: �t.�f�b.� �l �`�t'(S�`N <br /> State License# $G\�09 3 Expiration DatE: �j 3( <br /> Lead Certl6cation Number� �j �[� � �$� � �xp9ratEon Date: � <br /> (far work on homes fhat w�ere consb~rrcted�ricr fo�978 (cell) <br /> Phone: �DS�� c�r ��(�O�� ,ti (offiCe) <br /> Mailing Address: � ••�,•• UJeSk C'{Y��Dscv; � ZlP: 'SS I +3 <br /> Contact Persort' Agplic�ant is: rrtr� r / Horneowner (Ct�c�a ano� <br /> Email arid/or F�X: <br /> PROP�I2TY OWNER IN�ORM11�1.TION: <br /> Name: 1��h ��� d ' <br /> Phone (day): �01� �- � �1 <br /> Address: City: �IP: <br /> �maii andlor Fax <br /> PROJECT INFORMATION: ulre <br /> Type of Project: Any earth mov8ment may�q <br /> MCWD review d�perrnits: <br /> � Ddor(s) ❑ Remadel ❑Fire Damage Minnehaha Creek Watershed District(MCWD) <br /> 1$202 Minnetonka Blvd <br /> 0 Re-roof,asphalt 0 Repair ❑St�rm Damage Deephaven,MN 55391 <br /> ❑ Re-roof,cedar ❑ ResiOrat�on ❑Water Damag� p�pne: 952�71-0590 <br /> Fax: 9b2-471-0682 <br /> ❑Re-roofi,other(spoctiy) ❑Sid�ng �Other. (specify) minn hahacreg .ar� <br /> [��IVindow(s) <br /> Qveratl Pro'ect Pescrlption: lLti S i n� oc�r � a pc�#; o a �' <br /> Estlmated Canstruction Vaivatlon of Project(excluding land) � � 0 5• D b � , <br /> �� <br /> A�PLiCANT ACKNQWLEDG�MENT: � <br /> � . Agrees to provide a41 in{nrmativn required or requested by the 6uilding DeparU'nent; <br /> . Cer�lfies that ih� information supplled is trcie and �orract to the best of his/her icnowledge. The appGcanE recognlzes th8t they <br /> arA Solefy rAsponsible for submltfing a Gomplete applicatifln being aware that upon failure to do So, the Staff has no altem�4�ve <br /> but to reject it unti!it is complete; <br /> . Some or alt of tha information that you are asked to provide on this appllcation ls class�led by State law as efther pnl�ate or <br /> confldential. Priwate data is informati�n wh�ch generally cannot be givsn to the publlc but c�n be gtven to the subJect of the <br /> data. Confidential data is information which generally qnnot bA glven t0 either the publiC or the subject of the data. Our <br /> purpose and intended use of this Information �s to annualty update our reCords and records of other goverrtmentai agencles <br /> re uired b law. 1 u retuse to su ! the infiormation,the a licatfon ma not be lssued_ / <br /> AoolicanYs Sianature: �� Date: � �)I� / <br />