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10/18/2012 10:53 7635251566 THE UPS STORE 1886 l� PAGE 01/61 <br /> , �� <br /> . � � <br /> � City of Orono '�� <br /> Building Permit Application for Maintenance / Renovation <br />� (windows, doors, siding, re-roof, etc.) <br /> Me�ing Addreas: Permit number, 070!7,-Oi o <br /> 0 PO Box 88 <br /> � O� �O Crystal Bay,MN 5532'.�U066 DeEe reveived: /a-! ��� <br /> � �, Sbeet AddreBs: Reoelve0 by: <br /> 2750 Kelley Parkway plan reviewfee: <br /> j ���e Orono,MN 55358 <br /> � Tota�Fe� /�7 �5 <br /> Maln: 952-249-4800 Fax: 952-249�818 wuuw.ci.orono.mn.us <br /> Thls appllcatlon form must be comple�ed in.full and ail required Informapon must be submitted. <br /> Incomplefia appilcatfons will bo reh+rned. (Please print) <br /> �ENERAL INFORMATION: <br /> ob Site Address: %O 74� �d�rh� Lr� <br /> WIII thls be a Parade af tiomes.Itemodelers Showcasa liome or othe�Display Homa? Yes o <br /> Ifroei,e spaciel ev�nt permh Is requbed wilh Poliw Department and CI(y Council epproyel BO days prlor to the event. Shuttk 6ua senrlce wIM be <br /> iequlred uMess applicsnt de�nonahafea au1Rc%nt onslte parkiny is eveilable. Non pe►mdted ever►ts will not be elbwed. <br /> CONT _,.., , _� -._.__... - <br /> _ __ . . <br /> RACTQR I APPLICANt INFORMATION: /'� ' � <br /> Name: � ��� ' /� ��l . <br /> State Lloense# � xpiradon Date: <br /> �.ead Certificatlon Number: ExplreUon Oete: //_ iy— �/ <br /> I r�•�r on ha►►ea ati,e wei.eonsbucted p.iw co 9978 <br /> �hone: /�- AeZ ^' l�d� �o�) ���� <br /> ,Mailing Address: D/ f� ,�,ac,Jr City: ZIP: S",s'�/� <br /> �ontact Person: �jn ,{,��� plicant is: Co� / Ho eowner �ci�e on.� <br /> Email and/or Fax: f�q.� q�a�'�S�. <br /> PROPERTY OWNER INFORMAT�ON: . <br /> Name: � L.,1J �Yi,S� _ <br /> Phone(day): ZIP. � <br /> A►ddress: /D 7' � LriiE/a /�-✓� ���e � �d� <br /> � Emalt and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: My eaMh movemen!may requlre <br /> C]Door(s) Remodel ❑Flre Damage MCWD raview 8 peflnl6B: <br /> Mlnnehaha Creek Watershed District(MCWD) <br /> ❑Re�roof,asphalt Repalr ❑Storm Damage 18202 Mlnnatonka Blvd <br /> ❑Re-roof,cedar �R�toration �Water Damege Deephaven,MN 66391 <br /> Phone: 952-471-0590 <br /> �]R�roof,othor(sPac�y) ❑Siding 0 O�►er(spec:ify) Fax: 952-471-0882 <br /> �W���S� v�w.minnehahacreek.ora <br /> � Owrall P oct Descrlption: <br /> Estimated Constniction Veluatlon of Project(excludine land) � � pDl�' <br /> APPLICAN7i ACKNOWLEDGEMENT: <br /> . Agreeg to provide all inforrnatbn requfred or requested by the Buildir�Depa�tment; <br /> • Certlfl¢s ihat the information supplied is true and co�ect to the best of his/her knowledpe. The epplicent reoog�lzes that they <br /> ere so'ely responsible for submitting a complete epplication being aware that upon failure to do so,the statf has no altemalive <br /> but to reject it untll It is oomplete; <br /> � Some�or all of the irrfortnation that you are asked to provide on ihis appllc�tlo� ts classHied by S4aie law as either privaie o� <br /> � co�id ntlal- Private data is infortneUon which generally cannot be given to the publfc but can be given to the subject of the <br /> dete. �Cor�fMerrtial dats is ir�formatlon which generally cannot be g'n►e� to either the publlc or the subJect of ihs date. Our <br /> � Durpage and intended uae of this i�ormalion Is to snnually updete our rewrds and rewnis ot other govemmental aga�cies <br /> � re w b law. If u refuse to su I the informadon e a IlcaUon ma not be issued. <br /> ApplicenYs Signature: I �e: �����" �l� <br /> I I <br /> Lafi[Updaled: 0�-0�2011 - <br />