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• .. <br /> �' �ity of Orono <br /> Building Permit Applica�ion for Maintenance / Renovation <br /> (windows, daors, siding, re-raafy etc,) <br /> Mailing Address: Permit number: <br /> �,L�.j� PO Box 66 <br /> � „ Q Crystal 88y,MN 55323+0066 Date received: <br /> � "' a Stre�f Address: Rece�lrad by: �/�._ <br /> �` �$o�' 2754 Ke{Igy Parkway f�lan review fee: <br /> -��s� Orono,MN 5�356 <br /> �- Tataf Fee: ���, � � <br /> Matn: 952-249-4600 Fax: 952-249-4636 w��.ci.orano.mn.us <br /> This applicatlon forrrt must be completed in full and a[I required irzfpmis�otl must be submitted. <br /> Incotnple#e applicatlons will be re#urned. (Ple�se print) <br /> GENERAL INFORMATI(yN: ' 1�� <br /> Job 5ite Address: ( '�� ��� ����� <br /> Wil1'this be a Parad9 of Homes, Ftetttodelers ShoWCase Home or pther bisplay Home? Yes No <br /> !f yres,a specf8/eyent peimit is requlred wfth Police DspartmeM end City Cound!approV�!60 days prior to the event. 5hutUe bus service wll!be <br /> required unless applicarrt demonstrat�.a au/f'rcierrt oR-sr7e pa�king!s�vailabie. Non perml(ted�vanta wil!not 6e allowed_ <br /> CONTRAC70R/APPLICANT 1NFOt�MAY1pN: <br /> Narne: � \ �t °(�r��CSe�N <br /> State�.icense# �G 1�0`��3 �xpir&tio�1 Date: � �� <br /> �eed Certification Number: � � �"�.a$3 r E�cpiration Date: �f�c <br /> (for work cn hanes tbat were conatruci�ed�ui�r tv i978 " <br /> �hone: (nS j� a�(� --��Q�- (office) (cell) <br /> nna�lcn�Aaaress: 19� , i� ,° ,. w�s+ �i�v:"�u ;11� Z1P: S l3 <br /> Contar,t Person: Appllcant is: ontractor / Homeowner �c�rcr�ocm� <br /> �mail and/pr F�x: <br /> PROPERTY OWN�R INFORMATfO • <br /> Name: <br /> Phane(day): _�I-Cy�(�(.P <br /> Addt'ess: <br /> �maii and/or�ax C,�� Z��� <br /> PROJECT IN�ORMATION: <br /> �'ype of Pro�eet: <br /> /�ny earth mcvement may require <br /> []Door(s) ❑RsmoBe! ❑Fire Damage N�CWD revlew 8 permits: <br /> 0 Re-roo'F,aspha[t ❑Re air Minnshaha Creek Watershed D(str�t(MCWD) <br /> p �Storm pamage 18202 Minnetonka Slvd <br /> ❑Re-roaf,ceclar ❑Ftesforat(on 0 Water Da�r►age ��phaven,MN 55$91 <br /> Phane: 952�71-0590 <br /> Q R�roof,other(speclty� ❑3id�ng �]Ofher:(specify) Fex: 952-471-0682 <br /> ���a�s� v�,minnehai�acrsek,or <br /> Overal[ ProJect bescription: � C�J� � rY"l, r Y� <br /> Esttmated Constructton Valuation of Project(exciuding land) ; Q. � � <br /> APPLICANT ACKNOWl.EDG�MENT: <br /> • Agrees to provide all ininrmation required or r�quested by thg Buifding DepaRment; <br /> • Certifies that the information suppEl� ls true snd mrrect to the best of hts/Fter knowledge_ "fhe applicant rec�gnizss that they <br /> are solely responsible for submitting a c�mplete application being awars that upon fsiiure to do so,the staff has no alfemsbve <br /> but to rejsct it urrti!it!s compiete: <br /> • Some or all of Y,he information that you are asked to provide on thls application is classlf�ed by State Eaw as either privete or <br /> confidential. Pri►rate data is information which general�y cannof be giMert to the public but can be given td the subjecf af the <br /> data. Gonf�dential dat� is informa�on which generalfy cannot be glven #p either the publtc or the sub)ect of the data. Our <br /> purpose and intended us@ of this infiormation ls tp �nnually update our rec;ords and records of other govemmenta( agencies <br /> re ulred b law. If ou rpfiase to su ! the information,the a licetton rr� not be issued. <br /> An�licant's Sianature: �� Date: pl� ��� ���.l� <br />