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Oct 22 92 05:06p Kaufman Roofing 612-722-1021 p.1
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<br /> ' C�ty of Orono
<br /> Buitding Permit Application for Maintenance 1 Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Addness: Permit number. �� -
<br /> O.�O,�O PO Box 68
<br /> Crystal Bay, MN 55323-0066 Date received: /D- 3/
<br /> ,� ' a StreetAddress: Received by:
<br /> �, �G�' 2750 Kelley Paricway Plan review fee:
<br /> o Orono, MN 55358 ��� ��
<br /> Total Fee: ,
<br /> Main: 952-249-46U0 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications wlll be returned. (Please print)
<br /> GEN�RAL INFORMATfON: # � I
<br /> Job Site Add�ess: �Z�� L�(J�� �av� _
<br /> Will this be a Pa�ade of Homes, Remode�ers Showcase Home or other Display Home? Yes No
<br /> li y�es,a specia!evenf permit is requirad wlth Police Department and City Council approve160 days pNor to the event ShutNe bus servtce will be
<br /> required unfess applicant demonshates suficient on-site pericing is avai/eb/e. Non-parmlfted events will rrot"be allowed.
<br /> CONTRACTOR I I,PPLICANT INFO�MATION:
<br /> Name;; �,1�.,,r_,..�,�.� I�,z�,c..,,��, �
<br /> State �icense# _ 2 Expirativn Date: 3 i i
<br /> Lead�ertification Number: �;a�_5—�,�qZ_ � Expiration Date: ��--
<br /> (/o�work on bomes that were constructed prior to�978
<br /> Phone�: (�l'Z,: '}Z"Z,, G�11oa (office) �n�2.3t�� . i vt�3 (cell)
<br /> Mailin�Address: � � Cit : �L.S ZIP: • ���
<br /> Contaict Person: � ,�,� ' ti Applicant is: cto ' ! Homeowner �circ�e o�e�
<br /> Email�and/orFax: q rc{n� �3 �� ,.,��„rG�• ,,.� , �;,.,A
<br /> i -
<br /> PRORERTY OYYN INFORMATION:
<br /> Name: �����-+ ����� �. �
<br /> Phong (day}: �l 2_.. t'�y.�. �q..'�,c�.
<br /> Address: -- � City: �2¢:v`; ZIP: '^�� .
<br /> Email';andlor Fax � �
<br /> PROJECT INFORMATION:
<br /> Type qf Project: Any earth movement may require
<br /> ❑DoQr(s) ❑ Remodel ❑ Fire Damage N�CWD review 8 permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑Re�roaF,aspfialt ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd
<br /> R �roaF, cedar ❑ Resioratian ❑Water Damage Deephaven,MN 55391
<br /> el Phone: 952�171-U590
<br /> ❑Re�roof, other(specify) ❑ Siding ❑Other. (speciiyj Fax: 952-471-0882
<br /> ' ❑Window(s) www.minnehahacreek.orq
<br /> Over�ll Project Description:���� �,� ' ,{� p,�cF c,�,,,� ����
<br /> Estimated Construction Valuation of Project (excluding land) S •�4 ^'"Z� —
<br /> APPL'ICAIVT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information requi�ed or requested by the Building Department;
<br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes thal they
<br /> �, are solely responsible for submitting a complete application being aware that upon failure fo do so,the staff has no attemative
<br /> ' bul to rejed it until it is complete;
<br /> I
<br /> • i Some or all of the infor ' n that you are as ed to prov" on this apptication is classfied by State law as either prrvate or
<br /> confiderrtial. Private ata is information whi enerall cann b 'ven to the public but can be given io the subject of the
<br /> ' data. Confidential ata is i ormadon which nerall cannot gi en to either the public or the subjed of the data. Our
<br /> ' purpose and intend use o this information to an ually upd te ur records and records of other govemmental �gencies
<br /> I ce uired b law. If o refu to su the inf mation, li ti ma not be issued.
<br /> Or►nlirpnt'c Cinnati irv� C Date: `V Z� 1�.
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