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<br /> G�ty of Orono
<br /> Building Perrinit Application for Maintenance / Replacement! Renovation
<br /> (No structurat expansion. Only wrindavuss, doors, siding, ce-roof, etc.)
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<br /> � Crystal Bay,MN 5b323-0066 �hD�a';��+E�di�;;i�;;;;:;.i;;;,:q' ;+��; �.CY,;,:,;'%
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<br /> Main: 952-249-4600 Fax: 952-249-4616 wuu�a.ci.orono.mn_us '.;:���,:��N,r,,,,,�, .�,,��;y y,F;{;;+��,; .�":f;��,.. ,,..;.
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<br /> This application form must be completed in full and aU required information must be submitted.
<br /> Incomp{ete applications w111 be returned. (P/ease print)
<br /> GENERAl.ITlFQRAAATION' j� f�
<br /> Job Site Address: � ��� �r 15 P. Il� P cw� ►�t ) , ���!�r�.�r,� M Iv .�.���/ j
<br /> Will this be a Parade of Homes,Remodelers Showcas�HpmQ or pthaP Dlspl y H4nle? ❑Yes �Tlo
<br /> !f yes,d sAeCial evp»t pelmit is requiretl wifh Police Depadment and Cify Counal apprnva160 days prior to the event. Shuttls bus sendce wNl be
<br /> r�qulred unlsss appl;cant dsmonstratas sufRciant on,site padvng is 6vaila4le. Non-perm+ii�d ev�+fs wf!!not be aAowed.
<br /> GONT�L4CT�R/AP LICANITT INFORMATION�
<br /> Name: d u(5 t � (4 r r� �!'�n n, �
<br /> State License# Expiration Date:
<br /> Lead Certification Number: E�irabon Date:
<br /> (for rsro►1r on homes thaf were const�ucted prior to�97$
<br /> Phone: (cell) (office)
<br /> Mailing Address: � C . ` �,,� .U City_ Q �. Z1P: S � �`j
<br /> Gontact Person: p fi„�,� `}� Applicant is: Contracto / Homeowner �circ�a+Q�
<br /> .:^_�ll.� ��
<br /> Email and/or Fax: n o �r n� � s.0�n.onr� � 2.Q (`s i�,�rs r�S�CO r'h
<br /> PROPERTY OWN INFORMATION:
<br /> Name: -,- r r� y�
<br /> Phone(day)� _ �— �
<br /> Address: l��0 L.� u i w v 4-. C� �M n�s ZIP: J��3l� �
<br /> Email and/or F�x: v�[� t�rv��,a .,�,� G�r`n�ir� S ea c�s �nti p�r�-S. cn r-.-
<br /> PR4JECT INFORMATION: Overali 'ectdesai tion:
<br /> 7ype of Projec�: Any earth movement may atso require
<br /> I�Door(s) ❑R�nodel ❑Fre Damage �CN►G review&permits:
<br /> [�'€te-roof,asphalt �Repair ❑Sfiorrn Damage Minnehaha Creek Watershed District(MCWD)
<br /> 18202 Minnetonks Blvd
<br /> ❑Re-roof,cedar ❑Restoratlon ❑Water Damage Deephaven,MN 55391
<br /> ❑Re�roof.other(spacfir! 0 Siding Q pt}��:(sp��(jr) Phone: 952-471-0590
<br /> Fax: 952,471-0BB2
<br /> ❑Window(s) ___ www.mtnneha6.as�ek.orn
<br /> Estllnnated Canstruction Valuation of Project(excluding land) �
<br /> APpLICANT ACKNOWLEDGEMENT:
<br /> • Agre�s to provide all infarrnafion requlred or requPsted by the Building Departmer�;
<br /> • Certifies that the infartnaUon supptied is't�us and oorreCt to the best af his/her knowledge. The applicant reoognizes that they ar�e
<br /> solery r�esponsible fqr submitting a complete applfcatian being awara that upon f�ilure to do so,the staif has no alternative but to
<br /> rejed it until it is complete;
<br /> • Some or alI of the ir�inm�ation that you are asked to provide on this applic�tion is dassified by State iaw as either private or
<br /> confldential. Private data is inforrrtation which generally canrbt be given to the public but can be given to the subject of the data.
<br /> Confidential data is iriforma6on which generally cannot be given to eittter the public or the subJect of the data- Our purpose ar�d
<br /> intended use of thfs information is to annuslly update our reWrds and records o�F other govemmental aggncies required by law. If
<br /> u refuse to su I the i forma�on the a ' ' ma not be issued-
<br /> Applicant'S Signature: �G�. 1�-�0�-- Date: �o � S" �.�
<br /> Owner's Signature: � � �fie: � �$"/•3
<br /> Last Updated:03/06/2013
<br /> �oa�oo•d c�r� so:<< ��oz►s��so
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