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. e9"A26/2011 14:22 7635712746 JOHN PEDERSON CONST ,' f�, PAGE 01/01 <br /> n �� <br /> I��v''� � ��� �r <br /> � �� <br /> � <br /> Ci of Orono� <br /> tY ; <br /> Buildins Permit Application for Mainten n�e / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> MailingAddrosx p�rt�i{number: D -� �/� <br /> O.�(�,�0 PO Box 66 <br /> Crystal Bey, MN 553z3-0066 D i te received: <br /> � � St�et Addless: R�oeived by: <br /> 2750 Kaliey Parlcway Pl�n review fee: <br /> ��� Orono,MN 55356 � <br /> Tqtal Fee: �8'8' Q� <br /> Main: 952-249-4600 Fax: 952 249�4616 �nnw.a.orono.mn.us <br /> 7his applicatlon fnrm must be completed in full and all required inform�ion must be submitted. <br /> Incomplste applicattons wlll be retume . (Pleas print) <br /> GENERAL INFORMATION: ? ��, : � �j, -� <br /> Job Slte Address: J �✓ <br /> VYIII this be a Parade of Homes, Remodelers Showcase Home o�othe�Disp y�lome? es <br /> M yes,a apeciel eventpemm�ls requ'ved wdh Pdioe DeparM�ant and Cky Counal epp►oval 60 deys prior to the event. SbuWa bus�rWce wIu be <br /> requfred unless�pplicen!demonstrates suHfclent onsrte pa�fdng is aveileble. Nc,�perm�tted ewents w(Il nor be aliowed. <br /> CONTRACTOR/APP CANT INF RMATION: .•• <br /> Name: �p N � /1/ C� � 1/�"� , <br /> State License# Expi�ation Date: .3_ 3 - ,3 ^_ <br /> Lead Certiflcation Numbet: Exp'Hation Date: -� <br /> (for xrork on home�s that r+e Con e d rMr to 1978 � <br /> Phone: �G�� (Office) / j, l• /7Q (cell) <br /> Mailing Address: -7'7 ��/�/V� � City: �' - ZIP: � <br /> Contact Person: Applicsnt ls: / meowner �c�.�o�y <br /> Emaii endlor Fax: e I^S r'� �' . /�'� <br /> i <br /> PROPERYY OWNER�INFORMATION: ! <br /> Neme: j) I <br /> Phone(day): � � - ' � <br /> Address: �3 7 �a►r' �rV�� C�Y= ��/�/O ZIP: .:'-� .Z�� <br /> Email and/or Fax i <br /> � <br /> PROJLCT INFORMATION: <br /> 7ype of Projact Ahy earth movement may requira <br /> ❑Door(s) ❑Remodel ❑Fire Damsge � MCWD revlew�pennlb6: <br /> Mi��ehaha Creak Watershed Distrid(MCWD) <br /> �ie-roof sphalt ❑Repair ❑Sbmt Damage � 162oz Mi�netonka Bivd <br /> ❑Re- ,cedar Q Restoration ❑Water Damage : Oeephaven,MN 55381 <br /> i Phone: 952-471-0590 <br /> (]R�roof,other(6paciy) ❑Siding ❑Other.(speafy) ; Fax: 952-471-0682 <br /> �Window(�) ! www.minnehahacreek.ors� <br /> � <br /> Overall Project DesCri tlon: � � ! <br /> Estimated Construction ValuBtlon of P Ject(ex uding land) S ��� S/D=— <br /> ; <br /> APPI.ICANT ACKNOWLEDGEMENT: i <br /> • /Lqrees to provide a)I infortnadon required or requested by the Building Depa�tmeM; j <br /> . Certifiea thst th�Inbtmatlon supplisd is true and oorred to 1he best of his/he�knoVNedge. The applic2M recognizes that they <br /> are solely responsible for 6ubmi�ting a complete application being aware lhat upon�Fdilure t0 do so,the staff has no altemative <br /> but to rejeU it until it is aomplete; � <br /> • Some or all oF the informaGon that you a►e asked to provide on this application is�classified by Stale law as oither privste or <br /> wnfidential. P�ivate dats is infortnadon which generally cannot be given to the P4blic but can be given to the subject of the <br /> date. Co�fidential data is informstion whleh generally cannot bs given to eilher the public or the subJect of the data. Our <br /> purpose and iniended use of this inionnation i�to annuafly updabe our records and recortls of other govemment�l �qenaes <br /> re uired b law. If u refuse to I the informatlon e a lication me �ot be i ued. <br /> ApplicanYs Signature: (�ate; �•�3'�� <br /> �,eet Updated: 08-09-2011 � <br />