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�a��9 12 02: 12p TWIN CITY EXTERIORS CO 763 425 6457 p. 2 <br /> City of Qrono <br /> 6uilding Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> a,,�o� Mailing Address <br /> PO Box 66 Permit number: <br /> O Crygtai BeY� MA155323-0066 Date received: <br /> � a Sfresf Address: Received by: <br /> � 2750 Kelley P8rlcway <br /> �`$ Orono, MN 55356 Plan review fee: <br /> Main: 952-249-0660Q Fax: 952.24g.�g�g ww�,,G.orono.mn.us T�Fee: <br /> This application form must be compieted in ful(end all requfr+ed information must be submitted. <br /> Incomplete application�will be retumed, {P/ease print) <br /> GENERAL INFORMATION: <br /> Job 9ite Add�ess: � � S <br /> Wtll thia be a Parade of Homea�Remodeler�s�howcase Home or oH��r Display Home? Yes Na <br /> ��,a��e��I p�m►�t is requinal wrrh Po/k�Qepe�ent and City Counti!apProval 60 days priorto M�e even� Shulde bus�rvice wrll be <br /> iaqul�ed unless applicent demonsbates sul8cfent on s�9 Pedd�g!�evallab/e. Non <br /> CONTRACTOR/APPLICA IIVFORMATION: �pe��d e������ot be a1loWeal. <br /> Name: J <br /> State License# <br /> Lead Certificetion Number. �� �p���n Date: .,3 <br /> (for work on homes that were con�n,cted S� ExAiration Date: <br /> Phone: � Arior to 1978 <br /> Mailing Address: p <br /> 5-4� 3 (office) (cell) <br /> Contac�Person: � ���Y� ZIP: .��- <br /> -�'��d"� ����+���� Appticant is / Homeowner <br /> Email and/or Fax: �s�,�,;,J,��h �ci�c��o,re� <br /> �-�C �'�,fess o/Y1 <br /> PROPERTY OWNER INFORMATION: <br /> Name: I ^ <br /> Phvne(day): ��'�7_a_�,�� <br /> Address: �S/�f- �''� <br /> Email and/or Fa�c � ��� ZIP: <br /> PROJECT INFORMATION: <br /> Ty�of Project <br /> ❑Door(s) ❑Remodel A�Y�rth movement may requlre <br /> ❑Fire Damage MC1AlD revl�w 8�parmlls: <br /> ❑Re-roof,asphalt ❑Repair Minnehaha Creek Watershed Distrid(MCWD) <br /> ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Re-fooF,cedar ❑Restaratfon <br /> ❑Water Damage �eephaven,MN 55391 <br /> ❑Re-�oof,other(spectfy) Sidin Phone: 952-471-0580 <br /> 9 ❑Other.(specify) Fax: 952-471-0B82 <br /> ndow(s) www.minnehahacreek orq <br /> Ov�rall Proj�ct Desc�i ' n: <br /> Estimated Constwctian Valuatlon of Project(excluding fand) $ ,3 D I, <br /> Da <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • A9�s ro provide all informaUon required or requested by the Building Deparhnent; <br /> • Cer�fies that the infurmaticn supplied is true and c�rrect to tl�te best af hislher knowledge. The appGcant rc�ognizes that they <br /> are salely rasponsible f�or submitting a c�mplete applica�on beirtg aware that upon failure to do sv, t�e staff has no altema6ve <br /> but to rej�t it until lt(s�mplete; <br /> • Some or ail of�e informatlon that you are asked to provide on this applfc�tion is classified by State law as either private or <br /> confidentlal, P�tvate data fs infoRnadon which generally pnnot be given ta the public but can be glven to the subje�t of the <br /> data. Confide�rtial data Is Informetion whfch generally cannot be given to ei�er the public or the subjec�of the data. Our <br /> Iwrpose and 'mtended use of this i�ormation is to annuall u � <br /> uired b law. if au refuse to su I the irt ormation tk�e e li��tion ma�not���BSU��ds of other govemmental agenaes <br /> ApplicanYs Signature: ����� �_�__ �,�- n � �,..� <br />