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OCT�94-�ti�2.1 06:32 From: 6785736615 To:19522494616 Pa9e:2�2 <br /> City of Orono <br /> Building Permit Application foc Maintenance / Renovation <br /> wittdows, doors, siding, re-roof� etc. <br /> Me�ling Address: �- / <br /> �Q,� PO Box 66 Penni!number. O <br /> O O Crystal 8ay.MN 55323-0066 Date reoeived: <br /> � � SfisetAdd►953; Received by: <br /> 2750 Keltey Parkway Plan review tee: <br /> t,� � Orono,MN 55356 <br /> Tofsl Fee: ��I� G�,� <br /> Msin: 952-248�d600 Fax: 952-249�4616 .ww��nr ci.oronoLmn.us <br /> This application torm must be oompleted i�full and all requirsd information must be submilted <br /> Incomplete applications will be returned. (Please print) <br /> G�NERAL INFORMAt10N: <br /> Job Site Address: � �� �Vv� a►►'�'rt �� ' <br /> �II this be a Parade of Homes� modelers Showcase Home or other Disptey Honie� Yes No <br /> a yy�e�e�r pe�n►r;s�u;�ed w,��noe oePs�rme�u ane crry coun��►o�eo asys�ro u,e e�e sn�we eaa wa�ae <br /> isqulr�d unless eppbcant dernonafrates suli�cianf o�s►7�e pa�king fs availab/e. Nwrpe�events wAl not be s!►�owed. <br /> CONTRACTOR/APPUCANT INF MATION: <br /> Name: �� .� <br /> state ucense# ?�?SR 3 6�'6 Expiration oate: 3 �Z <br /> Lead Certidca6on Number. .- Expira�ion Date: ( <br /> (fnr worik on homes drat we�e constrrrc d pMor 1878 <br /> Phone: 6 I�� g l- (��) (oell) <br /> Mailing Address: �2, ;v�,. .' ��Y� ��S v� Z�P� <br /> Contact Person: ;� �� Applicant is: Mracto� Homeovmer �caa.on.� <br /> Email and/or Fax. qy�'.^ �� .� �'o.� <br /> PROPERTY OWNER ORMATtON�3• <br /> Name: �.�-� J C�o O +� <br /> Phone(day): <br /> Address: �ola �ur�" ��r••••� �o�► C'fi��r�o ZIP: SS 3 's� <br /> Email and/o�Fauc <br /> PROJECT INFORMATION: <br /> Type of Projeat Arqr ea movement n�ay require <br /> ❑poor(s) ❑Remodel ❑Fire Oamage MCYYD review a permib: <br /> Minnehaha Creek Watershed Districl(MCWD) <br /> ❑Re-roof.asphalt ❑Repait �$twm Damage 18202 Minnetonka 81vd <br /> Re-roof,cedar Restaration ❑Weter Oamage �eephaven,MN 55391 <br /> � � Phone: 952�71-0590 <br /> 0 Re�oof�othe►(spe�lry) ❑Siding ❑Other.(speaiy) Fax: 952-a71-0682 <br /> ❑Window(s) www.minneh}�,hacreek.ol't� <br /> Overall Pro ec!Desc�i on: (.e6r a►... f� <br /> Estimated Constructlon Valuation of Pro ect excludin land) i �D 000 <br /> APPLICANT ACKNOWLEOGEMENT: <br /> • �rees�o pro�ide eil informeaon required ar requested by�e 9uilding Deparlmenr, <br /> • Cerdfies Ihat Ihe ir�fonnatlon suppfied is Uve and correct to the best of his/her knowledge. The applicant recogn�Zes that they <br /> are solely responsibte 6or submimns a complete applicelion being aware that upon failure to do so,ihe staif has�o sltema6ve <br /> but to rejed it unGl it is complete; <br /> • Some a all ot lhe i�onn$lion Mst you ere ar.ked �o provide on this application is dasslfieQ by Stste law es either private or <br /> oonfldenlial. Private data is information whidf generally cannot be given to Ihe'public but can be given bo Ihe subJ�ot the <br /> 48fe. CoMidentfal data is ir�formation which genetslly Cannol be given to either Ihe public or Me subject M lhe dat2�. Our <br /> purpose end ir�tended use oi this informeGon is to annually update our reoords end reoords oi ofher govemmental sgencies <br /> uired law. Ii u reiuse to I the irt(ormalion the a Ikedon not be iss�ued. <br /> Appl'icant's Signature: Date: �� L � t ' <br />