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, , . City of Orono <br /> Building Permit Applica�on for Maintenance ! Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> ¢0� �� Pennit ruxnber <br /> O O Cryshal Bay,MN�532�0068 Daatiee rec�ived: <br /> Sheet Ad�ess: � Reoeived by: <br /> �'tts.��g�'G� OrOnO,MN 55356 P18n neView fe2: <br /> Total Fee: <br /> Main: 952-249-4600 �Fax: 952 249-4616 <br /> This a�lic�tion t�otm must be c�mpleted in full and ali required irrformation must be submit�ed. <br /> Incom�I appl�cafions ,�e returned. (Please print) <br /> GENERAL INF�RMATION: /?j�4 �l` }�G" . 1'� , J <br /> Job Site Addr�s: QI�tJ° /�/" ���J' � <br /> Wiil this be a Pa'ade of Homes, emodslers Showcase Home or otl�er Display Home2 Yes No <br /> If y�a speasl e�perm�t 1s fsquiied wRh Pnfice nepartmeirt end c;�ty CounaY appro�rre/eo ders piicr to the ev+�t sheRde bus serv�oe w�►be <br /> �4wred urN�ess appA�ant demor►sErat�es suAi�e�an-s�e p�Cfig�av�ablb. Nbn-Aem►xted erents wii not b�alb�r+ed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: � II C� ���/IS d n� ~ <br /> State Lioense# (�, G 3 r i�� _ ��«►�: 3 — .Za/ <br /> Lead Certific�tion Number. /�/AT- 1237 30—/ ����: '� — 2 O/7 <br /> (!o►wot�an homas tlrat w�ere oon�ru�ci�sd p�o►to 19T8 <br /> Phone: (oifice} ��� <br /> Mailing Address: �'�! 3 � i^ City: q 21P: SS��3� <br /> Contact PerBon: ° Applicant is: Contractor / FlomeoMrner (c�a.onel <br /> Email and/or Fa�c <br /> PROPERTI(OWNER INFORMA <br /> Name� ��� '���� <br /> Phone(day): <br /> Address: / r C�Y� t 0 n 8 ZIP: ���_ <br /> Email and/or Fax <br /> PROJECT INFORMATION: - <br /> Tme�� an�►eaMn movan�nt ma�►r+eqWre <br /> ❑Door(s) ❑Remodel ❑Fre D�nage MCWD revtew d�psrtnit�: <br /> Minr�haha C�elc NVabershed District(MCVVD) <br /> ❑Re-roof asphan ❑Rep�air ❑Storm D�unage 18202 Minnetonka Bhrd <br /> ❑Re-roof,cedar ❑Re�oration ❑Water pamage �,MN 56391 <br /> Phone: 9�i2-471-0.590 <br /> ❑Re-roof,dher(spectyr) ❑Si�n9 ❑Otl�er:(specifY) Fax: 952�471-0682 <br /> �S) <br /> Overall Pwject Descri p� <br /> Estimafied Cc�nstructfon Valuatlon of Proj (excludi land) S . <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to pnvide all iniermation r+equred or r�ed by U�e Bul�n9 Dep�Umer� <br /> • Certifies that tl�e infottnation supplied is true�d oorred to the best of hisJt�la�owledge. The applicant reoogrr�z�tt�at they <br /> are solely respor�sible tor submitdng a c�omple6e application being awar�e that up�f�ailune to do so,the s�ff F�ra aRemative <br /> but to rejecx it until it is complete, <br /> • Some or all of the information that you�e a�slced to pr+a�ride on this appNcation is dassifi�d by Sta�e la�ar as eilher private or <br /> oorKdenfial. Private data is iMortnation which generaqy caruwt be given to tF�e p�lic but c� be c�'ven to the subjed of U�e <br /> data. CoMiderrtial data is intormada� which ger�ady carxiot be given to eitt►er the pubNc a�fhe subjeet of the data. our <br /> purpose and irrtendad use of this information is fio annualy update oiu reoords and r�eoords of o�her goverrwner�al ager�aes <br /> uired law. tf refuse to i ihe icatiom m �ot be issued. <br /> ApplicanYs Signature: Date: �/� �` ��J�,-- <br /> i.as�uodared: os-O9-2o�� <br />