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OCT-11-z2� 07:36 From: 6785736615 To:9522494616 Pase:1�1 <br /> i ' . <br /> City of 4rono <br /> Building Permit Application for Main#enance / Renovation <br /> (windows, doors, sidin , re-roof, etc.) <br /> Mailing Addr�ss: Permit number: D 1 ���� <br /> O�O�O Crystel Bay,MAI 55323-006@ Date reoeived: �d/ / <br /> �, St►set Addness: Reoeived by: <br /> �a � 2750 Kelley Parkway Plan r�vieNv fee: <br /> � � Orono, MN 55356 ��� v - /� <br /> 0 <br /> Tot�l Fea: p ��� <br /> Main: 952-249-4B00 Fax: 952-249-4616 www.ci.oronq.mn.us <br /> This application form must be completed in full and all required information must be submitked. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Stte Address: 7.b"Lo � 1r W� <br /> Wtll this be a Pande of Homes� Remodelers Sliowcase Flome or other Display ome? Yes No <br /> It yes,a speclal event pemdt is required wilh Polioa Departme�t and City Council approva/60 days prior b fhe event ShulNe bus service will be <br /> ►equiied un/ess applicant demonstrates suA�iaent o�rsite paiJcing is available. Non perrniteed e�nts will not be a/lowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# � r������ �S(e Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for xrork on homes that were co�structed p�or to 1978 <br /> Phone: p�p � (office) �' 3 3 (cell) <br /> Maifing Address: �1, ' City: ZIP: <br /> Contact Person: ' Applicant is: Contractor / Homeowner �c►�one� <br /> Email and/or Fax: �`�� a S�„�,�,.���,����K . ��M <br /> PROPERTY OWNER INFORMATION: , <br /> Name: �r.. � <br /> Phone(day): ' � � <br /> Address: O City: C��1�.f. ZIP: <br /> Email and/or Fax • <br /> PROJECT INFORMATION: <br /> Type of Projsct: Any earth movemerrt may require <br /> 0�oor(s) ❑Remodel ❑Fire Damage MCWD review&pern�its: <br /> Minnehaha Creek Wetershed District(MCWD) <br /> Q�Re-roof,asphalt ❑ Repair (y�'Stortn Damage 18202 Minnetonke Blvd <br /> ❑R�roof,cedar [�'Restoration ❑Water Damage Deophaven,MN 56391 <br /> Phone: 952�71-0590 <br /> ❑Re-roof,athsr(specify) ❑ Sid'Ing ❑ Other. (specify) Fax: 95Z-a71-0682 <br /> ❑Window(s) www.minnehahacreek.om <br /> Overall Pro'ect Description: � - <br /> Estimated Constructlon Valuation of Project(excluding land) S 3 3�1.4�D .1`� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to provide all ininrmation required or requested by the Ruilding Departmer�t; <br /> • CsRifies that the information supplied is true and co�rect to the best of his/her knowladge. The applicar�t recognizes that they <br /> sre solely responsible for submitting a ccmplete app�ication bcing aware thst upon feilure to do so, the stafl has no altemative <br /> but to reject it until it is complete; <br /> • Some or all of the info►mation that you are asked to provide on this application is classified by State law as either private or <br /> confldenUal. Private data is i�formation which generally cennot be given to the public but can be given to the subject cf the <br /> data. Confidential data is irrformation which ge�erally cannot be given to either the public or the subject of ths d�ta. Our <br /> purpose and intended use of this informaGon is to annually update our reoorcJs and reoords of other govemmental agencles <br /> re uired b law. If ou�efuse to su I the inform on,the a lication ma not be issued. <br /> •_-�=---y- ^'---�•---. �1 'C.\ • — n..►.,. 1!� I 1� ' �1 <br />