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City of Orono <br /> Building �'ermit Apptication for IVfaintenance / Renavat�on <br /> (windows, doors, sid�ng, re-roof, etc,) <br /> .. r <br /> MailirrgAdd�ss: p��j�number: <br /> Q�O�O PO Sox 66 <br /> Crystal Bay,MN 55323-0066 Data r�ce3ved: � <br /> Recelved by: <br /> � � Street Address- _ <br /> � 2750 Keiley Paricway l�lan reviewfee: <br /> �'�� �,QG Orono, MN 55358 � <br /> Total Fee: � �� f�- <br /> Main: 952-248-4600 Fax: 95Z-249-4646 www.ci,orono.mn,c,?� � <br /> This appilcatiors farm must be cor►tpleted in fuii and ai) required irrformation must be submitted. <br /> Incomplete applic�tions will be returned. (f}lease p�int} �r�Sc4 ,_ <br /> GENERAL INFdRMATiON: � 2� � �,�� � 1�� <br /> Job Site Address: J <br /> Witl this bs a Paracf�of Homes, Retnadeler^s Showcase Home or other Display Ham�? Yes Na <br /> !f yes,8&pe�Quired u�ss appl�a t demonstra/tes�Su�c/ent on-si'Ye p�Rg!s ava�labl�.'Non-permltted vants w71 nOt b�Ilow6d en+ic9 wllf be <br /> CONTRACT'QR!APPLICANT iNFORMATEON: <br /> Name: '�re \ 'A'��[�'� � <br /> State License# '$C,13p`1 _ �xpiration �ate: 3 j 3 S <br /> Lead Certlfication Number: �j r � a$� � Expiration Date: '{ <br /> (for work on hom�s thaf were consfruct�tf pripr to 79�8 (�ell} <br /> Phane: (05l� c�l� —��0�$` �, (oi#ice) <br /> Mailing Address. � � •• „ W��h' ��tY��Sev; �, ZIP- SS I 3 <br /> ContaGt Person: Appllcant is: ont cto / Fiomeowner {cs.��e o�> <br /> Emalf andlor�ax: <br /> �ROPERTY OWNER 1 FORMA�"10 <br /> Name: ��► -f.t���"`�� <br /> Phone(day): 1 a• S� r �1 O <br /> Address: C��' Zf�� <br /> Emafl and/or Fax <br /> PROJECT INFURMATtON: <br /> Type of Pro]ect: Any earth mavement may require <br /> MCWD review&pemtits: <br /> ❑ Door(s) [] Remodel [�Fire Damag� Minnehaha Creek Watershed District(MCWD) <br /> �] Re-roof, asph�It �Rep�ir [� Storrr►Dam�ge 482Q2 MinnBtanka 91vd <br /> D�ephaven, MN 55391 <br /> ❑ Re-roof,cedar ❑Resioration [�Water bam�ge phone: 952-471-0590 <br /> �Re-rodf,other{speciiy) ❑Siding ❑Other.(spec�jr) �ax: 952-471-0682 . <br /> www minnehah creek.o <br /> ❑Windaw{s) <br /> Overail ProJect Descrip#ion: �G� �-{. t�..;r�dow5 t�l;� ��� ' <br /> Estimated Constructlon VaEuatlon af Pro (excluding land) $ q lA 0.0 <br /> APPLfGANT ACKIVOWLEDGEMEN . <br /> • Agrees tp provide�N information re red or qussted by the Bui{ding Departm�nt; <br /> . Csrtfies that the information eupplied is true and corr�ct to the besi o#his/her knawledgs. 3'he applicant recognizes that they <br /> are solety responsib}e for submitting s complete applicattors being aware that upon fa�fure to do so, ihe stafF has no altemative <br /> but to reJect it untll it ss complete; <br /> . Some or alI af tfie ��iormatlon that you are asked to provide on thls applicstion is alassi�ied by State law as either private or <br /> confidsntiai. Private data is information which ger+erallY cannot be given to the public but can be glven to the subject af fhe <br /> data. CRnfldenfia8( data is inforrnation Which generaily cannot be given to eiih0r the publEc or the subJect of the data. Our <br /> purpose and intended use of this lnformatiqn is to annueily update our recflrds and records of ott�er governrnenta! ag�ncles <br /> ra uired b law. If ou refuse to 8u 1 fhe info�rnati�n the a (icatlon ma not ba issued. <br /> Aot�licanYs Sianature: �a�" <br />