Laserfiche WebLink
� - . � C�ty of Glrono <br /> Building Per�mit Application far Maintenan�e / Renovation <br /> (windows, doors, siding, re-roaf, etc.} <br /> �a� MailPO Box 66 Permit number. �� 7 <br /> � 0 Crysta!Bsy,MN 5532�0(366 Date received_ cS–e�7" <br /> � Street Address: Recelved by: <br /> ,,`� 2750 Kelley ParkvvsY Pian review fee- <br /> ��,�+° Ornno,MN 55356 <br /> Totai�ee: <br /> 9Aain: 852-24g4600 Fax: 952-249-4616 www.ci.orono,mn.us <br /> This applic�Gon f�orm mus#be oompleted in full and alE requf�ed ir�formafion must be submitted. ^� <br /> lncomplete�pplications wlll be r+gturned. (Pl�ase prrnt) �o�a • �� <br /> GEN�RAL(NFORMATION: Q U c r���`�'� � �O f�-Q,. �� � <br /> Jab Site Addrssg: a -i .a <br /> Wiil#his be a Parade of Hom�,Remodelers Sh�w'case Home ar other Dlsplay Home? Yes No <br /> If yes,a speciaf eviar�f permlt/s►r�qulrod with Police Deparfinent and G'ty CouncA epprova/60 days prlor to the e+�sm. Shu1Ne bus servke wi11 be <br /> nequired unlpss applicant demonsha099 Suffklerrt an-site palldllg Is available. Nanyoe�r7'rKted events wlN n0Y be dllOwed. <br /> CON7RACTOR/APPl�1CANT INFORMATI�N: <br /> Name: t�l.�uJo.\ ��A��rSer� <br /> State License# �gG��p9 g�3 �xpiration Date: ��3► <br /> Lead Cert�ication Number: 1�3 f�'Y r c��'o��3 �1 �xpiratiort Date: ..,, y J 15 — <br /> (for w�aui�on homas that werr construcied prior to�978 <br /> Phone: �5�� o� ^�j�0�$- (of�ics) (cel!) <br /> Mailing Address: 19 olb C�. 1�d�•G•� W�S�^ CttY� � e �IP: S <br /> Contact Perso�' Applicant is: tra / Homeowner (c�ca o�) <br /> Email and/or Fsuc: <br /> PROPERTY OWN�R INFORMATION• 1 <br /> Name: �a Y�Yl � i T� � <br /> Phone(day): � � <br /> Address: Clty: ZIP: <br /> Emait ar�d/or Fax --- -- - <br /> PR4.lECT INFORAAA'I'lCN: <br /> Type of ProJeat: My earth movement may requlre <br /> �Door(s) ❑Remadel ❑Fire Damag� M��`������: <br /> Minnel�ha Creek Watershed�7istrict(MCWD) <br /> []Re-roof,a�phalC ❑Repair �Starm C�amage 18202 Mlnnetonka Blvd <br /> ❑Re-ropf,cedar �]Restoration ❑Water i3amage De�ph�ven,MN 55391 <br /> Phone: 952�71-Q590 <br /> [j RQ.roorF,otherlapeciiy) ❑Siding �Other.(specify) Fvc: 952-471-0882 <br /> Q Wlndow(s) ��1�_ � ��aC/�'"""'"�-minneha ek_or <br /> r� <br /> t <br /> Overall Rroject Desariptian: � <br /> Es#imated Constructicn Valuation of Project(excluding land S .� <br /> APPLiCANT ACKNOWLEDG�MENT: <br /> • Agrees ta provlds aA intvm�ation requlred or requested by the Buifding Departmert#; <br /> • Certlf�s that the information supplied is hve and aorrec�to ths best of his/l'�er fmowfecige_ The epplicarrt reoognizes that they <br /> are solely r68�ble tor submitfing a complete applic�tion being aware that upon failure to do so, the staff has no altema�ve <br /> but fo reject it ur�fii�t is CAmplete; <br /> • Some or all of tt�e ininrrn�Hon that you are aslced to provide vn thls application is clegsitfed by StHte law as eifher privaie or <br /> oonfidential. PtivBte da� is infom�atiron which generally cann0t be given to th� publlc but can be given to the &ubjer.t of the <br /> ds�ta. Canridsntial data Is Irrinrmation which generally cannot be given to either the public or the subject af the data, Our <br /> purpose and int�ded.use of thls information is to annually update flur reoords and rec�rds of other gqvemmental agenaes <br /> r ulred b law. If rePuse to su 1 the in'Form�tlon the a lication ma not be issued_ <br /> ADOI1CaflYs Sianature: �� �#e: �� `���� <br />