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Sep. 22. 2011 3: 22PM AC Construction & Restoration � ` R�� No. 5433 P. 1 <br /> � �` Cit of Orono "�'�� ` �i ����� <br /> y � � <br /> � � <br /> Bu�ld ng Permit Appl�cat�on for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address; Permit number: Q <br /> O�r D,�jO PO Box 66 � <br /> Crystal Bay, MN 55323-0066 Date reoeived; <br /> a �, StreetAddress� Received by: <br /> �. �� 2750 Kelle�Parkway Plan review fee; <br /> '�g��o� Orono, MN 55356 � <br /> Total Fee: ��9�/, �� <br /> Main; 952-249-4B00 Pax: 952-249-4616 www.ci.orono.mn.us "7-� <br /> This application form must be campleted in full and all required information must be submitted. <br /> Incomplete applications will be returned, ase print) <br /> GENERAL INFORMATION; �� <br /> Job Site Address: �_�_ �� <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? ❑Yes ❑ No <br /> If yes,a speclal event pennif ls required with Pollce Depertment and City Council approval B�days prloi to the event Shuttle Bus serviae will be <br /> rsquired un/ess applicant demonstrates su�cienr orr-site park/ng is avallable, Non PermKted events will not 6e allowed. <br /> CONTRACTOR/APP�ICANT INFORMATION: <br /> Name: C �C,oN3�a�c,l-;� d-� Q��3'a�rutT;aN <br /> State�icense# �.p(0 3� ( 3a Expiration Date: 3 3 ��'13 <br /> Lead Certification Number: �I Ar°� - (��{� c(- ( � � Expirakion Date: f!I a6t <br /> (for work on homes thet were constructed prior to 1978 <br /> Phone: �1(0 3' `t 1$` S a� � (office) C�(a'3 Is(o'�b�5�cell) <br /> MailingAddress: ��.5 I O �le'rc��, �N� S�n�� � c�ty: �a s ZIp: fyC ,s',�'j Y <br /> Contact Person: �y� Applicant is: ontracto Homeowner �c�►�e o�a� <br /> Email and/or Fax: RGC tZ�lt�c1 v c�.;c�N � C� w�!}_�, . C o1� <br /> PR�PERTY OWNER INFORMATION• <br /> Name: Vv���tz.\� �C o s;�e rz.A-�2 1�i <br /> Phone(day): (q(a- -�a 3 - 3'1 S'S � - <br /> Address: SG S l.�f►F S'� . City: �(1.�n�o ZIP: �s 3 5^a <br /> Email and/or Fax " <br /> PROJECT INFORMATION: <br /> Type of Project: A�y earth movement may requPre <br /> ❑Door(s) ❑Remodel ❑ Fire Damage MCWD revlew 8 permits: <br /> Minnehahs Creek Watershed Distnct(MCWD) <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> -roof, cedar ❑Restoration ❑Water�amage Deephaven,MN 55391 <br /> Phone: 952-471-059Q <br /> ❑Re-roof,other(specify� ❑Siding ❑Other� (specify) Fax: 852-471-0682 <br /> ❑Window(s) www.minnehahacreek.om <br /> Overall ProJect Descriptlon: <br /> Estimated Construction Valuation of Project(excluding landj $ o Oc�V <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building DepaRment; <br /> • Certifies that the information supplied is true and corred to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete applicetion being aware that upon failure to do so, the staff has no altemative <br /> but to reject it until it is complete; <br /> • Some or all of the inforr�ation that you ara asked to provide on this application is classified by State law as either private or <br /> confidential. Private deta is inFormation which generally cannot be given to ths public but can bs given to the subjact of the <br /> data. Confidentiel data is inform ' 'ch generally cannot be given to either the public or the subject of the data. Ou� <br /> purpose and intended use of t ' informatio ' to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refus o su I the infor tion the a lication ma not be issued. <br /> Applicank's Signature: Date: 7 �� ( "/'1 <br /> Ldsl Updated: 08-09-2011 <br />