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� SEP-28-2012 14:59 FROM:SCHMIDT-EXTERIORS 7638781343 T0:9522494616 P.1�1 <br /> . <br /> C�ty of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, �e-roof, etc.) <br /> ��� Mailip0 Box 66� Permit number. � L' l Z . ��.C�;� <br /> O Q Crystal Bay, MN 55323-0066 Data received: � � � Z <br /> � � � Sfroot Addresa; Received by: �1� <br /> 2750 Kelley Parkway Plen reviow foe: � �i <br /> �'� ��� Orono, MN 5535B ,y <br /> ��� Yvtal Fee� " �' I <br /> Mein: 852-Z49-4600 Fax: 852-249�816 www.G'.4f n .mn.ue � � 1 " <br /> This epplication fom�t must be completed in full�nd all required information must be submitted. <br /> Incomplete applicatione will be returned. (Pleese prynt) <br /> GENERAL INFORMATION' <br /> Job$ite Addreee: �����_ �T <br /> WIII thls be a Parad�of Homao, em delere Showcase Home or other Dlsplay HomeT�es Nc <br /> 1►yea,a spxlal event pam+lt ia requi�sd with Pollco Dape►tment and Clty Councll epprflval BO deya prlor ro the event Shuttk bua serolce wlll Oe <br /> roqulred unless appllcant demonst►atos SuIACb►It oii�.site pe/kinQ!s ev8116D1e. IVan-pemtltted ebnts will not Oe ellowed. <br /> CONTRACTOR/APPLICANT INFORMATI N: , l l L . <br /> Name: � ` � <br /> State License# � Expiration Dote� <br /> Lead Certificatien Number. Expiration Date: <br /> (lor work on homea aha�were construcrod pMor to 7878 <br /> Phone: _ (o�ce) '"'� Lp - y � - (� (cell) <br /> Mailing Address: Ci ZIP: <br /> Contact Person: Applicant is` ontractor Homeowner �a�ci.ono� <br /> Emeil and/or Fax' <br /> PROPERTY OWNER ORMATION: <br /> Name: ° � <br /> Phone (day): �'j _�,,,�� — 2 � <br /> Address: City�(�Q ZIP� <br /> Emeil and/or Fax <br /> PROJECT INFORMATIOAI: <br /> Type of ProJeCt: ���' Any ea�th movement may requlre <br /> ❑DOor(s) ❑Remodel ❑ Fire Damage MCWD r6vlew b permlt�: <br /> Minnehaha Creek Wate�shed Oistrict(MCWD) <br /> Re-roof,aaphelt ❑Repeir ❑Storm Damege 16202 Minnetonka Blvd <br /> ❑Re-roof,coder ❑Restoration ❑Weter Demage Doophovon, MN 55391 <br /> Phone: 952-d71-059Q <br /> ❑I�e-roof,other(speclty) ❑Siding I]Other(speciiy) Fax: 852-471-0882 <br /> ���d��6� m�r.minnehahacreek.ar� <br /> Overall ProJect Descriptlon; <br /> Estimated Const�uction Valuation of P►olect(excluding land) $ _ <br /> APPLICANT ACKNOWLEOGEMENT: <br /> . Agraes to provide all infortnation required or requasted by the Building Department; <br /> • Certlfles thet the information supplied is uue and correct to the beat of his/her knowledge. The applicant recognizes thet they <br /> ara solely responsible for submitti�g a complete applicarion being awsre tt�at upon failure to do so, the staff has no alternative <br /> but to rejaCt it until it is complete; <br /> • Some or all of the infermation that you ara esked to provide on this applicstion is claseffied by State law es either prlv8te o� <br /> wnfiden6al. Private dat8 is information which generally cannot be given to the publlc but can b9 given to the subjed of the <br /> dete. Co�fideritial data is iniormatlon whlch generally cennot De glvan to eithe� the public or the subjea of the deta. Our <br /> purposa and intonded use oF this Information is to annually update our �ecords and records oF oth�r governmantal agenaes <br /> r uired b lew. Ii ou refuse to su I the informotlo� t�e a lication ma not bo issued. <br /> Applicant's Signature: � Date: L� <br /> Leel Updated: OB-OB-2011 <br />