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City of �rono <br /> Building Permit Application for Maintenance / Repl�cement/ Renovation <br /> (No structura! expansion. Only windows, doors, s�d�ng, re roof, etc ) <br /> MeilingAddrass: �ern�dtrtu�rtber � ;,' ''`� � � k�;�l�'� S <br /> � Wp Box 66 � <br /> ��� ,, }�� Crystai Bay, MN 55323-0066 �� D�t�rs�eive��i ;', , , `�` �`" /�p <br /> � . ' ` , '' i� <br /> 4, Rec:�ived bj! ��� �� t � ° <br /> Straet Address: +�� , �� •., � e ;.. � , � �, , ;� <br /> �` �C'' � ti��'. �'1�1 2754 Kelley P2rkw�Y '� �Rl�rl tbvi�W f�� ' v? �'."4�.___�.'� <r,: <br /> � �� �� ��� ��� l,�� Orono,MN 55356 �"; ' � �',��, ai �� ���� rti <br /> ''�' sn�� Total���q " ,ti;,, , ; , , , ' <br /> Main: 952-249�3600 Fax: 852-249-4616 www ci.orono.mn.us '%: ` ;;�; �`"'� � ;r " J':` ', . <br /> This application forrn must be completed in full and all required information must be�submitbed. <br /> Incomplete applic�tions wiil be returr�ed. (P/ease pr�nf) <br /> 6EN�RAI.INFORMATION: �� ,� j� ,U� <br /> Job 5ite Address: (i�-► <br /> WIII this be a Parade of Homes, Remodelers ShowGase Home or other Display Home? ❑Yes o <br /> 11 yes,a speCia/avent pemrr�is raquirud wflh P�olice Department and City CounCr7�pprova!60 days pnor to tite evomrrt Shuffle bus seNlce w10 be <br /> requfred un(ess app/iCdnt demonstrates sutfiCiertt Rn�lte parking is Av3ilabfe. Non-pe�mitted ev9nts wlArrot be aUowed. <br /> CQNTRACTOR/ PLlCANT INFORMA ION: <br /> Name: j'�(T�.VI � `D1��' <br /> State License# �j Expiration Date: � <br /> Lead Certificatian Number: � p Expiration Date: a <br /> (for wark on homes that were conatruct�d prior to 1 S78 <br /> Phone: f�� �DIYCC'�' ' �Lti (��) � ' �--�2b� <br /> Mailing Address: $Z,.q � w - ZIP' <br /> Contact Person_ �yZ Applicant is: Contracto / Hnmeowner (Circle Ona) <br /> Email and/or Fa�c' " . -- �? � . � � ` <br /> PROPERTY OWNER INFORMATION: <br /> Name: (� l'�"�'1 �Q�7�1 <br /> ��anE�a�y�� � �2 .t�t�n �5 3510 <br /> AddresS: `�`�U ^ � ^'�"f� � t-e City. � �IP: <br /> Err�ail and/or Fax: mm ----r <br /> r� ' � �pa���� <br /> PROJECT INFORINATION: 4verali ro'ect descri tion��'15'�-�� � U �U� �'�'��- ��� � <br /> Type of Project: Arry earth m vement m8y also requlre <br /> ( ) MC1ND review�permlts: <br /> �Door s ❑Remodel ❑�ire Demage <br /> �F��raof,esphalt �epair �Storm Damage Minnehaha Cr�ek Wakershed District(MCWD) <br /> 18202 Mirtnetonka Blvd <br /> ❑R�roof,cedar ❑Restaration [�Water Damage D�ephaven,MN 55391 <br /> Phone: 952�71-0a90 <br /> ❑Re-roof,other(sPeC�Y) �Siding �Other(specify) Fax: 952-a���o6sa <br /> ❑Window(s) www.minnehaha�r�k.otq <br /> �stfmated Construction Valuatlon of Project(excluding land} $ 0— <br /> ApPLICANT ACKNOWIEDGEM�NT: <br /> • Agrees to provide all in4prmation required or requested by the Building Departmarrt; <br /> • Cer#�es that the infarmatian supplied iS#rue end correct t�the best of his/her kn4wledge_ The applicant reoognizes that they�re <br /> solely responslble for submitting a complete applir„�tion befng aware th8t upon failure to do sd, Ehe staff has no altem8tive but fo <br /> reject it untal it is complete; <br /> • Soma ar elt af the inform�tion that you are �sked to pravide on this application is cl8ssifled by State law as either private ar <br /> coMidential. Private data is infarmatiot�which generally cannqt be given to the public but can be given to the subject of th�data. <br /> Confldentiai data is information which generally cannot be given bo either the public or the subject of the data_ Our purpose and <br /> intended use af this info ation is to an I te our records and records of otheC governmenta!agBnCies required by iaw. If <br /> ou rafuse to su the infotm e - ' n ma not be issued. <br /> ApplicsnYs Signatur�9: Dete: <br /> Owne�'s Signature: ���e= <br /> Last Updated:03/88J2013 «C�lGt/ `�_G ` � <br /> �, !/ ( <br />