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84/82/2612 15:35 8800609860 MMMMMMMMM MMMMMMMM PAGE 61 <br /> � , 4 <br /> ... _..__.___��-�-^ <br /> Cit� of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> windows, daors, sidi�g, re-roof, etc.) <br /> �,r O,� M� POABox 66 Pertnit�umbe� O! - r� <br /> O � Crystal Bey,MN 55323-0088 Dete reC�ived: �-o�—,/a-. <br /> � � ,, StreetAddiess: Rooeivoa bp: <br /> �,�" 2750 Kdley Parkway p�a„��,�,�: <br /> � Orono,MN 55356 <br /> --- Total Fee: G} n <br /> Main: 952-249-4600 Fax: 952-249-4616 �vw.ci.orono.mn.us � / •.`� <br /> This application form must be completed in full and all required informativn mu9t be submitted, <br /> Incomplete applicAbions wlll be retumvd. (P/ease print) <br /> GENEqAL INFORMATIpN: <br /> JOb Slta AOdness: <br /> WIII thls be a Parade of Homes�Remalelers Showcsse Home or s�Dlsplar Hame? Yes No <br /> II y�s,a spepa►evenr pemNt Is�quheC wrtn Pbuce Depertment e�d Cify Courlal epprove/8�deys priar Qo d�e euent Shu1He bus se�vice will be <br /> requircal unlos3 oppli�ant dcmonsbaf�ns suNF.�ivnt on-sil�pBrkrny is avai/abltr. Non-pe�miYf@O eve►!ts Wi11�t bB 6NOw�BO. <br /> CONTRACTOR/APPLICA INF RMA110N: ' <br /> Name: �'. /j�af/�l,�y/1 <br /> State Lioense# )�.�f��i Expiration Dahc: fl <br /> Lead Certification Number. Expiration Date: <br /> (Ior wo�t on homes q►st wae consQuct�sd prio►Do 7979 <br /> Phone: �1-f'6�"lOpG (office) (Cell) <br /> MBiling Address: City: Z�p; " <br /> Contact Person: ,�� �Q, Appiipnt is: ontra r / Homeowner �c��or�� <br /> Email and/or Fax: �( a/ee.-y @ �fw�,d.'l, C�os., .., <br /> PilOPERTY 01111NER INFORMATION: � �j <br /> NamB: QG R A�,'Ar f� �� <br /> Phone(day): / - - <br /> Addr�ess: ,. e. c � Ciry: Q,✓�jA zIP: ,rJ�J`(C <br /> Eman anaior Fax ,n�cd .e ..h c., r���IY.!'a.� e•��•� I.c�w <br /> PROJECT INFORMATION: <br /> Trps vf Project: Any BaM m�v�meM may roqul�e <br /> (]Door(s) ❑ Romodel ❑Firs Damage �������: <br /> �Re-roai,asphslt ❑Repeir ❑SGom�Damege Minnehsha �02 M netonka Blvda�MCWD) <br /> O�Bpneven,MN 55391 <br /> ❑ Ra-roof,cedar ❑ Restoration ❑Water Damege Phone: 952-491-0580 <br /> ❑R�roof,other(apsolyl ❑Siding ❑Other. (sp�ciiy) Fax: 962-471-0682 <br /> ����5� vuww.minnehahacreek.ora <br /> Ove/sll Pro"eet Descri ' n_ <br /> Estimabad Constructlon Valuation of Project(Qxcluding land) � � O U.DO <br /> APPLICANT ACKN�WLEDGEMENT: <br /> . Agrees to provide an inronnetwn�equire0 or requestea ay me eui�amg aepartmem; <br /> • Celtifies thet the inbrtn�Gon supplied is true and correct to the best af his/her kno�Medge. The appliqn[ reCognizes Lhai they <br /> are solely respvnsible for submitting a cvmplete epplicalion being swsre that upon failure to do so, the stsff has no altemaativve <br /> but to rejad it uMil k ia oomplelo; <br /> . Soms or el! of!he infom+adon that you are asJc4d to prvvids on this applic�tion is dacsified by State lew as eithe�private or <br /> confldential. Private data is inrormeUon whlch peneraly cannol be piven to t�e DUDIic Dut can De �iven to tl�e SuOiect oi the <br /> data. Confldential data is ir�famation which generelly cannet be given to either the public or the subject of the data. Our <br /> purpo9c and intcnded u�e of thia information is ta annually update our reoords and records of other govemrr�ental agencies <br /> uired Isw. If ou refuss to su the' mtet' ,1ho a �Cetion ma nat be issued. <br /> ApplicanCs Signeture: Date: <br /> 1.00t Updaled: 06-09-2011 <br />