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' City of Orono <br /> � Building Permit Appiication for Maintenance 1 Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSI4N) <br /> O M�Hinq Adclmss: P�rmit rwmber. ��S'C�� <br /> � �TO PO Box 66 <br /> C►ystsl Bay,MN 55323-0066 Date recehreci: �� �(1 (� <br /> Streef�Iddr�ss: " Received by; __..._.___ - <br /> s�, fi 2750 KelleY P�ckwa Cy i �'a p �ian review tee: �., "-�y�___ <br /> -� <br /> ��XESHO �'` Orono�AAN 5�356 ��'�1 �� _ � <br /> R _ _ . .__u_ -_ <br /> _�_ _ <br /> `�.__ _ - --- --- 7otal Fea: <br /> Matn: 952-249-4600 Fax: 952-249-4646 �nrww.ci.orono.mn.us <br /> TF�s application form must be completed�futl and atl req�dred information must be sul�n�ted. <br /> Incomplet��pplications wiil be return�d. (Pk�se print) <br /> GENERALINFORMATION: ��/� A� �+�/�_,�� �n• ����� yy�iv SS39/ <br /> Job Ske Address: /v J 7a7L <br /> Will this be a Parade of Homes,Remodslers Shawcase Home or othor Diapiay Home? Y�s No <br /> H yes,a apecla!event psmHf ls r�qutred wkh PoNce Daps�tmerM and C!ry CouncA approva!60 dsys p�lor to tl►e event. Sh�tk Gus servke wiN be <br /> requked unl�ss�µpC�csr#der►wnstratas suA'ic�ent on-s�e parking fs avaHsble. Non-permRted evsrds wdl not be alloHnad. <br /> CONTRACTOR/APPLICANT INFORR�ATION: <br /> Nam�: _„SGl�h2l��'J�- 1Ls5 <br /> State Ucense# '7 Ex�ration Date: � 3! /� _ <br /> Lead Cerfification Number: �ItT /N / 9 Expiraiion�ate: � <br /> (for wor�on homes itu►t were construc d prbr to l978 <br /> P��: ���a . . y� (offtce) � qsZ•Y6 s� 35 S z <br /> Maf�ng Address: City: �' p ZIP: 3 <br /> Contact Person: �Npy � Appti�n#1s: ract I Momeowner �ckd.a+et <br /> EmaN and/or Fax: ��p ��;,�,�pP,yl, eryp�t��5.C.oM <br /> PROPERTY OWNER INFORMATION: <br /> Name: T��1f?'S L'ONN�"LC�I <br /> Phone(day): ��fG • !{25• �f5 0 8' <br /> Acfdress: �i�5 N S�i�� T?IZ �tY� �KZ1�t'� ZtP: �53� � <br /> K <br /> Email�nd/or�ax: -t-r•,�„��J�,`,�, /� 4Yh1'�1 j� <br /> PROJECT INfORMATION: Ov�r�� 'ect descri tion: Cl�'L� ���a��7--"' <br /> Type of Proj�ct: Any earth movement may aiso requtre <br /> ❑Door(s) �Remodal ❑Fire Damage MCWD revfew�permits: <br /> ❑Re-rooi,asphait ❑Repair [)Siorm Damage Minnehaha Creek Wa4ershed District(MCWD) <br /> 98202 Mir�etor�ca Blvd <br /> ❑Re-root,cedar ❑Restor�tfon ❑Water Damage Deephaven,MN b5391 <br /> �Re-roof,other;speciry) p s�a;rg p oit,er.t�Pecxyj �►�� 952-471-Ob90 <br /> Fax: 952-471-0682 <br /> �WindoHr(s) www.minnehahacreek.orq <br /> Estlmated Constructton Valuation of Project(excluding land) s D. �'' <br /> APPLICANT ACKNOWLEDt�EMENT: <br /> • Agrees to provide a!I information recp�red or requested by the Building Oepartment; <br /> • Certlfies thal the Mtormation suppNed 1s true and corred to the best of hislher knowledge. The app6caM recc�gnizes that they�re <br /> sotely respon�tble br s�mttt�►g a complete appHcation being aware th�t upor►fsFlure to do so,the atatt has no atiemati� but to <br /> reject#t un1N H is c�mplete; <br /> • Some ar aN of the �formaUon that yau �re esked to prov3de on q�is appicaiian 1s classified by State law as �ther p�ivate or <br /> con�dent(al, Private data is N�formation which Qenerally cannot be given to!he ptrblic bt�can be given to the aut�ject ol lhe dala. <br /> Conftdential data l�Mformation wFdch gener�lly cannot be giv�n to Eiti�er the pub�c or the aubject oi the daia. Ou'purpose end <br /> k�tended use af Ifiis fnformatlon is lo anrtusNy updale our records and records of other govern+r►erital agencies required by law. �f <br /> ou refwse to s t informatbt� !h� ' ibn ma not be i�sued. <br /> �ppticant's�nature: ��te: <br /> Owner's Sigr�at�xe: „� ��x• r..�� Date: �f��?oJS <br /> Las!l)pdated:January 2015 <br />