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- • City of Orono <br /> Building Permi# Application for Ma�ntenance / Renovation <br /> windows, doors, siding, re-roof, etc. <br /> MalUng Address: permit number. —��9 <br /> O�,O.�O PO Box 68 <br /> Crystal Bay,MN 55323-ooss pate received; -o�f>/ � <br /> .. Streef Address: Reoeived by: <br /> � o$ 2750 Kelley Parlcway Plan review Eee: <br /> � Orono,MN 55356 <br /> T�al Fse: ,� O I. I� <br /> Main: 952-2d9�600 Pax: 952-249-d616 www.G.orono.mn.us <br /> This applica�on form must be completed in full and all required information must ba submitted. <br /> Incomplete applieations will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: '�t,J�. <br /> Will this be a Parade of Nomes, modelers Showcase Home er other Display Home? Yes No <br /> I►yes a speaal ev+enf permh is n�qulRed Polior Depa►tme�and Gity Councll app�oval 60 days pr9or to the event. Shutde bus sarvlce will be <br /> ieyulred unless appllcant onsMdtes sul�ident on-sita pa�irtng is evailable. Non pennieted evsnts wiill not be allow�d. <br /> CONTRACTOR I AP UCANT INF RMATION: <br /> Name: '�� � I5T ��c.6 (:.+�.� Co. <br /> State License# � �, Expiratlon Date: M�A�N 31 ,aDl3 <br /> Lead Certification Number � 7.� Expirstion Dete: � �.�30.�p� <br /> (for w�ork on homes at wer�can trucEed pria to 1978 <br /> Phone: �.a� � (office). ��Q$5� (cell) <br /> Mailing Address: � ��q�t� City: ZIP: SS <br /> Contact Person: $„e.. Applicant is: Con ractor / Homeowner (Grcb 0�) <br /> Email and/or Fax: '��,k , <br /> PROPERTY OWNE INFORMATI N: �K �� "-V� I S38S � 0�71 F1cP. (� � C�%7�I <br /> Name: <br /> Phone(day)� GJ .Epi.�._ <br /> Address: L, � -i�,�, Ciiy: (,�y,�, �� ZIP: `jsJ.S�o <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any eaRh movement may require <br /> ❑Door(s) ❑Remo el ❑Fire�amage MG���eW�`��'�� <br /> ❑Re-roof,as hak Minnehaha Creek Watershed Dislrict(MCWD) <br /> p ❑Repai ❑Storm�amage 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Resto tion ❑Water Damage ��Phaven,MN 55391 - - - <br /> Phone: 852�71-0590 <br /> ❑ Re-roof,other(speciry) ❑Slding �Other:(speCity) Fax: 952-471-0682 <br /> ❑Wind s) �u,��,J�,q�� �•minnehahacxesk.ora <br /> Overall Project Descr�ption: a� � <br /> Estimated Construction Valuatio of Pro)ect(excluding land $ O' <br /> APPLICANT ACKNOWLED�3E ENT: <br /> • Agrees to provide all infortnatio required or requested by the Building Department; <br /> • Certifies that the information s pplied is true and correet to the best of his/her knowledge, The applicaM reoognizes th�t they <br /> are solely responsible for sub itting a complete application being aware thet upon failure to do so,the staif has no altemative <br /> but to reject it uMil it is complet ; <br /> • Some or all of the infortnation that you are asked to provide on this application is Gassified by State law as either pnYate or <br /> confidential. Private data ia i rmation which generally cannot be givsn to the pubilc but can be given to the subjed of the <br /> data. Confidentisl data is in rmation which generaly cannot be given to etthsr the public or the subject of the data. Our <br /> purpose and intended use of rmafion is to annualy update our records a�d records of other govemmental agencles <br /> re uired b law. If u refus ths ir�formabon,ths a lication ma not be issued. <br /> ApplicanYa Signature: .Z. Date: �,It,�l G�� ,��ol <br /> Last Updaled: OS-09-2011 <br /> Z,T:a6pd 9T9b6bzzS6��l Sd33MS J,3�XId �I�d!'�w��� SS�60 ZtiOZ-OZ-'lflt <br />