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16/69/2014 14:45 952-935-9544 MN RUSCO PAGE 02
<br /> . . � City of Orono
<br /> Building Permit ,Appficafiiort far Main#enance / F�eplacement ! Renovation
<br /> (Na structural expa�sion. Otlly w�ndOW3, daors, siding, re-roof, etc. '
<br /> .....:.............
<br /> A,. 1�emiif°rturrtbe�� �;`'�'`'';� g'
<br /> �. Mailing Address: � „ ; .:';r;�..�i :�-.4;'�i�?�'.
<br /> � �,V PO Box 66 ?,.� ;_;�': ;��c• �� ���� �,a�;,,,Maa�r;��i;:.,; "
<br /> � Crystal�ay ; ; �r, ,`c,;;.,�,,.,s::;�
<br /> ,MN 55323-0086 �-Date;rec�ivedi;��.;; ?�;,��.�,I�,� �'a'�`�'��'°. I��
<br /> ,:,�,;, ;���� ''!�"' .l',� r.�piiil���;,i� M' •.r�.� ����1:�.�'
<br /> �Reoeivecl��by;��; '• �'r'"' �;�
<br /> Street Address: `I" " -
<br /> :�:,_;�:���� �ia ..�;;,�, � :
<br /> '��, �' 2750 Kelley Parkway :.Plan:,revi9V�l.fi�e; µr�"i;�� �';�'"ii�`�`:=�-'�.'
<br /> � Orono,MN 55356 �;y,�;;::;�;. ;:��� ,i:;,������r;r:;:r�:�::i��,,,�,,; ;.;v;:;;�r:�;,;,.:,�;,:,,:._,
<br /> tH; � a.�:,�-r.:r.:,�� <'�`� �:I:r' ,�,�`�'^�.;�I�- ;r,��" I� .G;;:r
<br /> �� o ,.Tot�I.Fee:i�r'�:!`'I'�;; �.,,. ,�'� ��.:,,'�'I.+"� ':I�+y�-�. '��
<br /> s.N� il:�: .: �,i. �d .��.��.:;�
<br /> Main: 952-249-0500 Fax 852-249-4B16 www.ci.orono.mn.u� ��;?;:,���" ��' ,�� _ �.��"°'L"` "�'° '� �
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<br /> 'This appli�2ition form must be c�mpleted in full�nd afl requ'treci informafion must be submitted.
<br /> Incampl�te applicat�ons wiif be returned. (Please printJ
<br /> GENERAI.IN�ORMATIO{1E: r1^ 01r f� ���✓ I Vl1 DY��O �l 1/ '� �J
<br /> Job Site Addr�ess: .JV
<br /> Will thls be a Parat[e of Homes,Rernodelers Showcasc�Home or other l�isp ay Horr�e? Yes o
<br /> If pes,a SpeCia!avcnt permlt is fequlrod wlth PGIce Depertmorrt arrd C!ty CounCr7 ppprova!80 dayJ prfar to the event ShuM/e bus seMce w/ll be
<br /> IBqufred unless eppnCant dmmonsfrates Stlf�ipent or►-sA'e parking IS avar7able, Non-permRfed events will not be alfaw�ed.
<br /> CC�NTRACTORlAp LICANTINFO TION: /1��
<br /> Name: ����� ���Q��'� ---- -- -
<br /> State License# p0,�� Expiration Date: . Q3•,����
<br /> Lead Certific�tion Number. ��3}��Q �xpiration Dafe: �����/�
<br /> _ -
<br /> (for work on homes tl�at were consfrrlcted pnlor#01978
<br /> Phone: (celp rjZ� �}�5' � (office) 9�' ��p' �f�,�
<br /> Mailing Address: J�t¢,�. City: ZIP: �
<br /> Corrtact Person: �� � _ Applicant is: on fa o / Home�wner �c„s�oa,.t
<br /> �mail and/or�'ax: ��,v�—'�o?�.,J��,�aS�J�r(,�r rn• •
<br /> PROP�R't`Y OWNER INFOFtMAT10N:
<br /> Name: �/�I4Q�� �
<br /> Phone(day): Q5Z-
<br /> Address: " `� City: ZIP: � �
<br /> �meil and/or Fa�c
<br /> PRQJECT lNFORMAT�ON: Overall ro ect descri tion: � �►LG►� l� l� .
<br /> Typa of Project: Any earth movemenit may aiso requiro� �J Q/
<br /> AACWD revievu&permlts: "''��
<br /> �Door(s) (]Remadef ❑Fire Damage U
<br /> ❑Ra-roof,asphalt �Repair ❑Storm Damage Minnahaha Creek Watershed Distrid(MCWd)
<br /> • 18202 Mihn9t�nka Blvd
<br /> ❑Re-roof,cedar [I Restoratfon ❑Wat�r Damage Deephaven, MN 58391
<br /> � R9-roof,other(spec�iy) ❑Syiing ❑Gther:(specify) Phone: 352-471'0590
<br /> Fax: 852-47i-�62
<br /> m�Window(s) www.minnehahacreEkto�
<br /> Estimated Construction Valuation of Praject(excluding land) $����7^—�-"
<br /> APPLICANT ACKNQVYLEOGEMENT:
<br /> • Agr�s fi provide all Information required or requested by She Building bepartment;
<br /> • Cerdfies that the information supplled is true and Carreet to the best af hfs/her Imowledge, The�pplicar�t rocognizes that they are + `
<br /> solaly rospcnsible fa�submitting a complete applicatfan being aK+are that upon failure to do so,the staff has nfl altemativva but to
<br /> rejec�It until it is complete;
<br /> • Some or all of the intermation that you are asked#a provide on thls appfication is classified by State law as either private or
<br /> CollfideTltial. Prfvate dat8 i9 itlfoRnation whlch goneralty oannot be given ta�e publlc bu!qn be glwn to the subject of the data.
<br /> Cor�AdeMial datg is inftsrmat(san w ' generally cannot be given to elther the public ar#ha suDj�ct of the data. Our purpose and
<br /> ir�tended use oi this infarmation is annualty update our rec�rrls and records of other gov�mmental agencies required by law. If
<br /> ou refuse to su I the info a' the a 'ca n ma not be issued.
<br /> ApplicanYs Signature: Date: �
<br /> Owner's Signature: Date:
<br /> Last Updated:03l0612013
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