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JAN-9-z017 12:44 FROM:TREBILFOUNDRTION SYS 3205938720 T0:19522494616 P.2�3 <br />, � <br /> C�ty of Orono <br /> Building Permit Appl�cation for Maintenance / Renov�tian <br /> (windows, doors, siding, re-roof, etc.) <br /> ��--� MailrngAddress: Pdrmitnumber: /7—Udc�/ <br /> /Q�U�Q Pp Box 66 �_ 9 _ � <br /> Crystai Bay,MN 55323-4066 aate received: ,_ ___ _ 7 <br /> Stroet Add►ass: Receivod by: <br /> �� 2750 Kelloy Parkway PIaf1 r6Vlew fee� <br /> �e�.�xo�.¢ Orono,MN 55356 <br /> - To���oa: i ga,53 <br /> J�1ll�in� 95?..�249.de0Q Fax: 952»249-4618 <br /> This applicak+on fprm must be completed in full and all required informetion must be submitte ,�(�6 _/ <br /> Incomplete appl9eatlQns witl be returned. (Pleaso prfnt) �/�✓�"� E�'`j <br /> G�NEI�AL INFORMATIQN: 'J � ! r� <br /> Job 9ite Addre�s: '7 rUY�,,7� Q� ��� <br /> Wlll thls be a Parade o1 Hdmes,Remodelers Showcase Hom�or other play Nome7 Yes Na <br /> N y�,a SpoC1AJ event pelmff i8 roqu�red with Po1iCe Department and Crty CpunCr!app�pvs!60 days prip�to the eMent. Shuttle bus servrc�wiN be <br /> roqulrod unles8 epplican!damarstrates suMcienf on•�ite pedcing!s avallable. Non-permltted eironts wllJ nat be albwed. <br /> CQNTRACTOR I AP I.ICANT INFORMATION: <br /> Namg' �jL�.c„�i�" �jct,d�/hpa . <br /> Stata Licens�# �xpiration Date: --�/ -- � <br /> l.e�d Certification Number. _J Ex iration pate: <br /> P �-3/-�.,i ,_ _ <br /> (for worK on Aomes thet wore construci�ed pH to 9978 I <br /> Phone. (ot�ce) (cell) <br /> Mailing Address: v City; � ; zIF�: ,� <br /> Contact Person: ' ��� t Applicant is: . ontra / Homeowner (Clrele Gne) <br /> EmBil�ndlvr F�x: �i y7 �jq- ��.p��� '�d <br /> PROpEI�'F'Y f�WNER INFORMATION: , <br /> ��fTl9: �1� ����i`1L�...— /C�/�/ <br /> Ph�ne(day): � � <br /> � � <br /> �,/�,�_c�1.7—�� , <br /> Address: �-Jy-r.�{2��'1PS�' �����- C�tY� �0714 ; ZIP,�.S3ln�� <br /> Em�il and/or Fax <br /> PROJECT INFORMATIQN: <br /> Typo oi ProJect: Any earth movemant may requlre <br /> ❑ Door(s) ❑R�m4del []Flre Damage MCWD revtow�permlts: <br /> MinnQnaha GrBeK WBtBr�n6d UlgtriCT(MCWD) <br /> ❑Ro-rpof,asphalt ep�ir Q Storm DamagO 18292 Minnoionka Blvd <br /> ❑R�roo#,cedar ❑Restoration ❑Water Damage �eophovo�, MN 55391 <br /> Phone: 952-471-0590 <br /> C]Re»roof,other(spec��y� �SlC�lfl� []Other. (specify) Fax: 952-�171-0692 <br /> Q Winclow(s) www.minn�,hah,�reek,;Q,r4 <br /> . <br /> Overal!Project Descriptlon: � <br /> ---.... . _.. ...._ <br /> �stlmated Constructi�n Valuati4n of Pro�ect(excludln land) S � <br /> APPLICANT ACKNOWLEDGEM�NT; <br /> • Agrees to provide all informatian required ar requeateG by the Building DepartmenY; <br /> • G�rtifies that the informailon supplleC Is truo and correc[to rhe best of his/her knowledge- 'rhe applEcanC recognfzas that Chey <br /> are solely responsible for submin�ng 8 opmplete application being aware that uppn failure to do so, tha staff has no alternative� <br /> but to rejeCt it until it is comploto; <br /> • Some ar aii of the information that yau are �sked to provide on this applicetion is dessified by St�te law as aither pnvate or <br /> contltlenttaf. Prlvat8 d2ta is infarmation whlch generally r,2nnot be given to the publlC but Cen bp giyBn tp the BuDject of the <br /> data. Confdential data is information which generally c8nnot be givan to either the publlc or tne sUbJeCt of the tlBCa. Our <br /> purpoee and intendvd usv of thia information is to annuoiry update our recnrds and records of vthar gov�rnmantal agencies <br /> re uired b I�w. IP ou refuse to su I the information the a lication ma not be issued. <br /> AppliCant's 5ignature: , �� pate; _ �-'-��� <br /> L0g!UpOpfOd: 08•09-2011 <br />