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FROM:T0:19522494616 03/28/201215:29:30#651 P.001/001 <br /> r . - ' <br /> City of Orono <br /> Building Permit l�►pplication for Maintenance / Renovation <br /> windows, doors, siding, re-roof, etc. <br /> Mailing Address: p��number; o?oi -oo <br /> • <br /> O�r ,�O PO Box 66 <br /> Crystal Bay,MN 5532�0066 D�e reoeived: � <br /> � � Sbeet Address: Rece��ed by: <br /> 2750 Keliey Parkway p���f�: <br /> �� Orono,MN 55356 <br /> Main: 952-249-4600 Fax: 952-24&4616 www.ci.orono.mn.us r�F�: ��""�� <br /> � This application fortn must be completed in full and all required infortnation must be submitted. <br /> Incomplete applications will be returned. (P/ease�int) <br /> GENERAL INFORMATION: <br /> Job S1bs Address: S Hd A <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Oisplay Home? Yes No <br /> K y�s,a spedel event permJt/s requied witi►Polke Department and C![y Councll approval 80 days prior to N�e ev�nt Shufde bus service wNl be <br /> _ requked uMess epplkant denwnstiates suA9dent oo-slte perldnp Is available. Non-pennitted evertts wtl!rat be allow�ed. <br /> CONTRACTOR/APPL,ICANT INFORMATION: <br /> Name: KR�cN �x tfRr���L S <br /> State License# 'ZpsB 3Z7�1 Expiration Date: -Z p�y� <br /> Lead Certification Number. Expiration Date: <br /> (fior wnrk on homes tl�at w�ne constructed prioi to 1978 <br /> Phone: ��-�. �'&�r.(�2���r �" (office) Ce/l (01 a . �o�/�. l�� L (cell) <br /> MailingAddress: City: s,�r � Z�p; �5�17 ^ <br /> Contact Person: Q�Lc.. �"_ APPlicant is: n / Homeowner �c��.on.� <br /> Email and/or Fax: �S�, qqN . /3�r g- <br /> PROPERTY OWNER INFORMATION: <br /> Name: S�zs�S c.,�U�. <br /> Pnone(day): ys a•��ni. 9 3�b <br /> Address: 3�8G NofLTN SNDKE I�A. C�tY� (�YZ.�4Tq ZIP: S'-53��/ <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: My earth navement may require <br /> � MCVYD revisw 8 pern�ib: <br /> ❑Door(s) ❑Remodel ❑Fire Damage Minnehaha Creek Watershed Dishicc:t(MCWD) <br /> ❑Re-roof,asphait �Repair ❑Siorm Damage 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage DeePhaven,MN 5539'1 <br /> Phone: 952-471-0590 <br /> ❑Re-roof,other(specty) Q�Siding ❑Other:(specify) Fax: 952-471-0682 <br /> � ❑Window(s) www.minnehahacreek.ora <br /> Overall Pro act Descri tion: rvnwrNG t]��/FS O F SNccc1 d- R£- ST VCCC� SA+� tcx.��� <br /> � Esdmatod Construction Valuation of Project(excluding land) i a S, 1 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provfde all ir�formatbn required or requested by the Building Department; <br /> � • Certi�es that the information su lied is true and oorrect to the best of his/her kn <br /> pp owledge. The applicant recognizes that they <br /> are sotely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemadve <br /> but ta rejed it until it is complete; <br /> ( • Some or all of the ir�foRnation that you are asked to provide on this application is dassified by State law as either private or <br /> confidentfal. Private data is informaUon which g�eraily cannot be giv�to the public but can be given to the subject M the <br /> data. Co�idenGal data is iniom�atlon which generally cannot be given to either the public or the subjed of the data. Our <br /> � purpose and intended use of this infomnation is to annualy update our reoords and reoords of other govemmental agerxies <br /> uired b law. If ou refuse to su the iMortnabion,the a licadon ma not be issued. <br /> 1 Applicant's Signature: �'"�" Date: 3. 2a•/Z <br /> 1 <br />