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06/O1/201� 7:01 AM FA% 16125796615 SIMON CONSTRUCTION f� 0002/0002
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<br /> . City of Orono .
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doars, sidin , re-roof, etc.)
<br /> Mailinq Addross: � ..�`...•".:.....: "
<br /> � O.� POBox66 ���Pe,r,r.n�t��ii7rtjber::��•;:;..�'����-.'�":..:.:$',.
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<br /> 0 � Crystal Bay.MN 55323-0066 :��sCe;�eqei'v,ed�:;;�;";.;;""•"::::`•:�� :.�.,�'l:'��'J:�. �� �
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<br /> �. SlrcotAddress: �;�i�'��;:�::�':�.;:;�..... �;;�;"'':"a''' :°��'.;:::::
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<br /> • 2750 Kelley Parkway � ,,,,,,,,,,,,,,,,,,,,,,,•,��,,,.,,,,.,::...-.„•••:,......... . ..:.�•.. .,.,.,.........,.
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<br /> '� oa4 Orono.MN 55356 -a:�°°°�... ..�
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<br /> . Main: 952-248-4600 Fax: 952-249-4616 www,ci.orono.mn.us ��� '
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<br /> This application form must be comploted in full and all required information must be submitted.
<br /> Incomplete applications will be returned. (P/oase print)
<br /> Jo Si Address:NWTION: � � LU�� L��v� l��dL` . Q�'C'�o �f V ��J� f
<br /> Will th' be a Parade of Womes�Remodelers Showcasa Home o her Display Nome� Yes No
<br /> K a apedel ov�enr pomdr!s roou�roar w�tn vo►;ce oepertmonr and ehy,Councl�approvmi sp daya prlor ro che eironc shumo ous sonrie,wi�oe
<br /> roqulred uMoss npplken!dw►�onshs(�ea sufyicier�t on.slto pn�k/n�Is avpll�0le. Non-psrmifted evcnts wlll not be allowod.
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<br /> . 0�17 CTdR/APP ICAN`�"I FQ1,2MATION: �_
<br /> Name: ..� r� ✓� �. rn �wC �r'on �
<br /> State nse# ., q 7� Expiration Date: � /
<br /> Lead rtification Number: � �-j�j �� Expiration Date: f S
<br /> ' (for rk on homes that�conabucMd prior to 19T8 �
<br /> Phone: � 'Z- .S� I - �70C G� (��e) (cell)
<br /> Mailing dress: '3 � 'v� � l� v� . City: ;;/'h �v�� ZIP: �j >"�
<br /> Contac erson: Y�,.�,�„� �,.,.,�,,.�,� Appli nt is: on / tiomeowner �cacie one�
<br /> Email a d/or Fax: ' �12�• 573 ���, /.�
<br /> �;r� c 4�rv�C✓i[o/�_S'1�C�/cn Cc�,,, _
<br /> PROP TY OWNER ORMATI N;
<br /> Name: �j,� � �►�-
<br /> Phone aY)� I2— -. �. IZ3 •-• ^
<br /> Add SS.S LVCt �:.-�.' �G�cl�..r�_� City. �%+�er1.c� ZtP: S'S 7 Jr 7
<br /> Emall d/o�Fax �
<br /> PROJ T INFORMATION: �
<br /> �Type o1 roject: ����r Ariy eBRh movem�nt rriay roqulro
<br /> ❑Ooo ) ❑Romodol ❑Fire DamaBe MCWD rovlow&paRnit6:
<br /> Minnehaha Craok Watershed District(MCWD)
<br /> ❑R� f,asphalt ❑Ropair Q Storm Dama�e 18202 Minnetonka Blvd
<br /> ❑Re- f,ceda� ❑Restoratan ❑Wator pamage � �eophaven, MN 55391
<br /> ❑Ra ,other a c ) � Sidin Phone: 952-471-0590
<br /> ( P� KY 9 �Otherr.�(sPecitY) Fax: 952-471-0682
<br /> ❑1Mndow(s) �'� I�r ��,.��. �me�minnehahacreek.ora
<br /> overa�� ro'ect�escription: /'�n�o✓� s � % S � �� � /��P �� ��:::�.� a l s i ��
<br /> Estim d Conslruction Valuation of Projec!(excluding la d) � S l.(Q�'OO�j � �
<br /> APPLI NT ACKNOWLEDGEMEN7: '
<br /> • grees to providv all fnformation required or roqucstod by the Building�epartrnerrt; ���
<br /> • ertifies Ihat!ho ir�tonneGon supplied is true and correct to the best of his/her knowl�dge. The applicant rocognizos tfiat they
<br /> solely responsiblv tor submitGng a complete apptiption being aware that upon failuro to do so, the staff has no altomaavs
<br /> � t to rejett It untfl it is complete;
<br /> • me or all oi the Information that you are asked co provide on this applic.ation Is Gassified by State law as el�her ptivate or
<br /> nBden6al. Private d� is iniOrtneGon which penerally cannot bo glven te the public but c�n be glven to the subjed of the
<br /> ta. Confidential deCa ls information whkh yeneraly cannot bo glven to e'ither the public or tho subJeCl o! the data. Ou�
<br /> rpose and intended use of this informaUon is to annually update our rorards and reoords of other govcmmontal agencies
<br /> uired b law. If refuse�su I thp(nformetion,!he a lication ma not be Issued.
<br /> Applica s Signature: --�' Date: C� � ( z
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<br /> �sc upda : oe-os-zo�,
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