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Gity of Orano <br /> ` <br /> Building Permit Application for Maintenance / Renovatian <br /> (windows, doors, siding, re-roof� etc.� <br /> Meil�n8 Address: <br /> '�0� PO Bwc gg Perm(t number: o?D/aZ. -• V D � <br /> .� Q Crystal B�ay,MN 55323-0066 Date received: <br /> � � Slmst Addr�ss: ReCsived 6y: <br /> 2750 Kelley Parkway <br /> �o��' Orono, MN 55358 ���j���' <br /> Mal�: 952 249�i800 Fax: 952-249-4516 �wy.ci.orono rnn us Totel Fee: f Sz .�� <br /> This application form must be comple�d in full and aQ required irtforrnadon must�submitted. <br /> Incomplete applicatfons will be returned. (P/ea�pr�itt) <br /> GENERAL IAIFORMATION: <br /> Job Slte Address: y 0y� N.S t 1� i V�2, <br /> Will this be a Parade of Homes� Remodelers Showcase Home or athe�Dispfay Home? Yes No <br /> �'res,a s�ecie�e►re►rt pen.,n�a►trq�d+ed wrHr Paurr,e Depa►ar,ent ana►c,Zy councA apprv��ea de <br /> r�ulred uNess a p � Y8 Pri'or to the event Shtrtde bus servloe wfli be <br /> pP�t demanetrales sul�fClevrt au�-site ark)n Is eve/lable. Afon-pem�fted events wJU notbe aflawed. <br /> CONTRACTOR/APpLICANT INFORMATION: <br /> Name: '�1 tthe.wo.� �Av�trSe,N <br /> State Lioense# o�,��07�3 Expiration Date: 3 j�,l <br /> Lead Cettification Number. �j��_ a�.�$3 -i T Expiratlon Date: <br /> (Ir�r work on hanes that were�an8br�ci�ed prlor to l978 ��I S <br /> Mail1 g Address: � �SI- a -.�}� � (�Ce) . (cetl) <br /> Conta�t PersOn: ' Wc Ciiy:��G i G ZI�. ss <br /> Applicant Is: / Homeowner tca�as o�„I <br /> Ernail and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �� � G�r� . <br /> Phone(day): 45 0l-4� -ylo 53 <br /> Address: �S��k CItY ZIP: <br /> Email and/or Fax <br /> PRQJECT INFORMATION; <br /> Type oYProject: <br /> Any earth mavemeM may r,equine <br /> ❑Door(s) ❑Remodel ❑ Fire Damage �C����8(�►+��: <br /> ❑Re-roof,�phalt �R e�� Mlnnehaha Creek Watershed Dlstric�(MCWDj <br /> eP ❑Storm Derr�ge 18202 Minnetonka Blvd <br /> ❑Re-rocf,e�a� ❑Restoration ❑Waier Oamage Deepheven, MN 56391 <br /> ❑R�roof,otl�er(apeat�y) ❑Sldt�g Phone: 952-471-0590 <br /> ❑��r(�Y1 Fax: 952�71-0882 <br /> �1M�ow(s) ]�Iw.mfnnehahacx�ek ora <br /> OveraliProectDescrtption•'R��p�� � �s WI�� �`�� o �;�,� <br /> =��'.':'•o Q���.��ucuvn va�uat�on of Proj6ct(excluding Iarldl � lo� 13y o� <br /> APPUCANT ACKNQWLEDGEMENT: <br /> • A9rees to provide ell fr�formetlon required or re�uestad by the Building Deparbnen� <br /> • Certifles that the Inflormatlon sup�lied is trt�e and correct to the�st�f his/her knowledge, The applirsnt recognizes tFmt they <br /> ere sately rrespor�sible for subrntttlng a compleie applic�tlon being awere that upon failure to da so.the ataff h�s no al�emative <br /> but to reject ii un�l it is complete; <br /> • Some or all oT the informatian tl�at you are asked � prpvide on this appiica8an Is classified by State lew� @tther private cr <br /> r.�nRdentlal. Private data is information which generaliy cannot be gfven �the publfc but can be given to the sub�ecx of tho <br /> d�te. Confidentlal data Js ir�fomnatfon which ganerally cannot be given b� sith@r the public or t�e subJect o�t the dsta, pur <br /> purpose end iMended uas of this Informatton (s io annually update our reconds and reoards o�f c�ther govemmental agendes <br /> u(red b lavy, IF ou refuse to su I the informatian the a Itcat;on ma npt be Issued, <br /> Aoolicant's Sianature:����-�r`+DQ� Date: a3 <br /> 1�� <br /> z 'd 06t9bG9TS9 3�Ih213S 1IW213d Q '8 S i� SS � T T ZTOZ EZ �eW <br />