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City of Orono <br /> �ui�ding Permit �►pplication for Maintenance ! Renovation <br /> (windows, doors, siding, reMroof, etc.) <br /> Marling Addreas_ PeRntt number� �/ � <br /> ����`yO Crys2aXBay,MN 55323-Q066 Daf.e rsce➢vsd: �' — 7 <br /> Received by_ <br /> ��+.� 1� � 5treet Address � �' <br /> , 2750 Keiley Parkwey plgn review fee: <br /> ���$����,� Qmno,MN 55356 � �� 2� <br /> Total Fee: vL <br /> Nlain: 952-248-d6Q0 Fa�c= 952-249�616 vvw��+a ci.orc,Zno.m�i,� <br /> This appllcation forfn must be comp{eted in full and all requited infofsn2tlon must be submitted. <br /> {ncomplete applicatlons wi11 be returned. (Please pt�nf) <br /> GENER/�16 iNFORMA710N: q ag .���� �� <br /> Job Slte Address: <br /> Wilf�thts be a Parade of Hom�s, Remadelars Showcase Home ar ather D�splay Hom�? Y�s o <br /> !f yes, a specia!evsnt perm�t Is requ/red wlth Polica Department arrd City Council approval 60 dsys pr�or to the event. ShutiJe bus servlce wil!be <br /> r�qufred unless appficant demonatrates sulf7cient pn-srte parking?s avail6b/e. lVon-pem�ltfed aVents wl11 nof be alloW6d. <br /> GONTRACTOR/A�PLiCANT INFORMATION: <br /> Name: �£ u�b•\ 'A`��°��'N <br /> State Llcense# �G��b�1 � �xpira#ian Date: �(�S <br /> Lead Certification Number' <br /> N `�� a�,a$3 � �xpiration Date: '� <br /> (for work on homes that were constr'uct�d prfar to 98�'S� (��c�) (Cell) <br /> Phone' ���� c�� "'��0�' ZIP: <br /> Mailing AddreSS' o'�� , '� `• r. CyJ�. ��tY��}e.V,l � SS �� <br /> Contact F'erson: Applleant is' ntra r / Homeown�r �c;rc+e o�o� <br /> �mai!and/or Fax= <br /> PROPERTY OWt�IER iN�ORMATlON: <br /> IVame' S 'n �� � <br /> Phone (day): - �r � �� ZIP: <br /> Address: � City: <br /> Email and/or�ax <br /> PR4JECT INFORANATION: Any 0arth rnovamerrt may requlre <br /> Type ofi Project: M�Wb revlew&perrnits: <br /> ❑Door(s) ❑ Remode! � Flre I�amage Minnehaha Creek Watershed District(MCWD) <br /> 18202 MlnnetOnka Slvd <br /> ❑Re-roo�,asphalt ❑Repa+r ❑ S#arm C7arnage Deephaven,MN 55391 <br /> ❑R�roof,cedar ❑Resf�oratlan [,�Water Damage Phone: 952-471-0590 <br /> c Sidin ❑Other(spe�►�Y) Fax' 952-471-06�2 <br /> ❑R�roof,other isPe �iy1 � g www_min nshac eek.or <br /> �Window(s} . <br /> �verai! Project Descr�ptlon: c� C.v� <br /> W/�n �Q..k i 5 � � i <br /> Estlmated Censtructlon Valuation of Project exaluding tand $ <br /> APPLiCANT ACKNOWLEDGEMENT: <br /> . Agre�s fo provide a(I In#ormatlon requfred or r�equasted by the Buifding Departmeni; <br /> . Certffies that the lnformafion supplied ts true and correct to the best of his/har knowledge. Ths applicant recogniaes that they <br /> are solely resp4nsiblA ISor subrrcftting a compleie applicativn being aware that upon failurs tn do so, the staff has no aftemative <br /> but ta reject iF untl(it is compiete; <br /> . Some or aA of the InfQrmation that you are asked to provide on thls applicatiott is classi�ied by State iaw as etther p�ivate or <br /> confldential. Private data is inf'ormation which generally cannot be given to the publfc but can be given to the subject of the <br /> data. Gonfldentia! data is Informatlon wt'ilch generally cannoi be given to either the public or the subject of the data_ Our <br /> purpose end I�tended us� of this informatlon is to annualiy update our records 8nd reaords of other govemmental agencles <br /> re uired b 12W. If u r�efuse to su I tha infbrmatlon,the a fication ma not be issued. <br /> �� ��t�: l4�/n�J /� <br /> Apolicant's Sianatute: <br />