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05/1�/2013 TU$ 14: 24 FAx 555 5555 LOCy $roe Homee �002/002
<br /> � ' �ity of Orono ao`.� -oa3�
<br /> Building Permit �lpplication for Maintenance ! Repls�cement/ Renovation
<br /> � (No structural expansion. Only windaws, doors, sidin , re-roof, etc.)
<br /> ( '� M�1!ingAddress: *, �d ,.,; ,:���•, ��.; '�� •..�:
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<br /> � PO BOX 66 � r , '' �••,„s•.:;.•,�••
<br /> ;', Crystal8ay�MN 55323-W66 p,�.,��:;�9�: r��.,", �;,.., ',:
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<br /> ,�, StraetAddress: '���;.�r;..,.�t;. ' � ; ; `:.
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<br /> 2750KeIleyParkwaY ::F�I' �.R,, :''' '"' ;,,�`.
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<br /> Orono,MN 55356 ,;�;�; ,,,: ,,���:� '���;,. '�<�;�: ��1�, � � . :
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<br /> Main: 962-249-4600 Fax: 852-24&4616 �vww ci.orono.mn.us ..,,�,.r&:;'`�';f'.'�;T;';;; �'',, ��•
<br /> This applic�tion form must be campleted In fulf and att required information must be submitted.
<br /> Incomplete appllcatJons wlll be returned. (Please print)
<br /> GENERAI.INFORMATION:
<br /> Job Slte Addrsss: ��S �I�VL'�.p"'r QFS
<br /> WIII lhls ba a Parade af Homes,Remodslers Showcase Home o�other Dlsplay Home? Yes�o
<br /> lf yes,�speciel event permit is requiied witl�Poi�oe�ps►bnent end City Councq 8ppvovel BO deys pAor M d1e eVenf. ShufNe bus se�vke w1H be
<br /> requlred urUeas applkanf dematshmtes suA�PClen!on-slte psrMrp Is ava!labfe. NorwparmKted events wlll not be albwsd.
<br /> � CONTRACTOR 1 APPLICAMT(NFORIIpAT ON: '
<br /> R A
<br /> Name: �r�� ��,
<br /> State License# ��y����� �xpiradon Date: �-��l--�1p I
<br /> Lead Cert'�i'ication Number: • Expira�an Date:
<br /> (for work on homee that were const�vcted pHor io 7B7B
<br /> Phone: (cell) (offlce) g�a-� .-��g�
<br /> Malling Address: �4 w C' : ZIP: e.�s
<br /> Coni�ct Persdn, �,h�qg �,,,�Nd��ti,-� Applic�nt is; Gontractor / Hameowner �ciroieo�e�
<br /> Emall andl ax G��-c�t���(bGg — _ ,_„
<br /> PROPERTY OWNER INFORMAT1pN:
<br /> Narne: Cy'�oi,r"k �, �(r1 �1�C,pl
<br /> Phone(day): T'�
<br /> Address: ��,S Ei�cti►� v� �g�S �nY'd�"�Y1 a zIP: �a�3 6�
<br /> Email and/or Fax:
<br /> PR4J�CT INFORMATION: Overall ro'ect descri tion:
<br /> � Type of Projact; Any earth movement may also requlre
<br /> ❑Door(s) �,]Remodel ❑Flre Damege AMC4UD revlew&permlt�:
<br /> []Re-roof,asphalt ❑I�epair ❑Storm Demege Minnehaha Creek Watarshed bistri�t(MCWD)
<br /> 18202 Mlnnetonkp Blvd
<br /> ❑Re-roof,cedar ❑ResMreaon ❑WaRer Damege Deepheven,MN 56391
<br /> Phone: 952-471-0690
<br /> ❑Fte-roof,other(speciiy� �,Siding ❑Other'(specliY} Fax; 852-471-�92
<br /> ❑Wlndow(S) www.mirt h
<br /> Estimated Constructlon Valuation of Prvject(excluding land) � �f�QLQo_
<br /> APPLICANT ACKNOWLEDGEM�NT: �
<br /> • Agnees b provlde all Ir�formas�tion required or requested by tha Building Dep�rdner�t;
<br /> . Certlfles that the Informatbn supplfed is tnae and wrrect to the beat of his/her knowledge. The applicent recognlzes Rhat they are
<br /> solely responsible for submiltin$a oomplete epplicefion being ewere that upon fatiure to do so,fhe staft has no aNernative but to
<br /> rejec�it until it ie complete;
<br /> • Some or all of the informatton thai you are asked to provide on this epplication 18 dassified by State law Qs elther private or
<br /> corifldential. Priv�te data is informetion whioh generally aennot be glven b the publlc but can be plven to the subjec�of the dete.
<br /> Confidential dete is ir�formetion wh(ch general{y cennot be given to e�her the pub11C or the subjeCt of the data. Our purppae and
<br /> intended usa of thie i rmaUon Is to annually u te our records and recards of other govemmentai ag�aes r�equl�ed by law. if
<br /> ou refuse ta su e Mormatlon th ' tlo ma not be issued.
<br /> Appllcant's SIgn2�ture: � Date: ��^/y`"��
<br /> �wners Signature; Date:
<br /> I A17�I IfY'IAMfI•n3mann�z
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