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' , , ��[�� � <br /> � <br /> City of Orono <br /> 6ullding Permit Applicatlon for Intemal Work <br /> • (windows, doors, sidin , re-roof, etc.) <br /> A�ailing Addresa: Permit number: O -+ DO�7 <br /> � PO Box 66 <br /> O�"' �O Cysts�gey,MN 55323-0066 Dstie received: .� <br /> Sd�aet Address: R��� <br /> � � 2750 Kelley ParkwaY Plsn roview fee: <br /> omno�Mro s�5s /D�'4.� <br /> Tolal Fee: <br /> AAain: 952 249�600 Fa�c 952-249-461B .ci.oro o.mn.us <br /> This eppllcatfon fam must be c�ompleted I�full and all required iniormation must be submitted- <br /> Incomplebe sppikadons will be retumed. (Please p►�nt) <br /> GENERAL INFORMATION: /�/' r ���5�� �''�I� <br /> Job SM�e Address: (S!t9 <br /> YYIII this be a Par�e oT Nom���o�S�Homs or olhar Display Homo? Yes No <br /> !f yes,e speder s►rent pen►dt Is�►r��orla��o�r+��e��$�- ���everrts�no hib�edowed�wY!ae <br /> i6pWred unle8a e�PhCant <br /> GONTRACTOR/APPLICA� INFORMATION: <br /> Name: /�9i�1 f�/�S�- Ieob���'3 s���� i�✓t�idQl� L�C <br /> St�ts License# � it D�l O� 7 7 Exp�ration Date. p3/.��/�i�r�_ <br /> Lead CeRiflc�tion Number. F.xpiration Dete: <br /> (For wark on homss lhat wero oonstruc�1��1978 0�) ,7 f' 3�0, � � (Cell) <br /> Phone: 76 3—�!? 7�q�96 ( <br /> Mailing Address: S r'+�' �1" City: A� iD�rZ ZIP: SS�y 6 4' <br /> CoMact Perscn- �nti/� G�� Applk�nt is: n r I Homeowner �c�.o�n� <br /> Email andlor Fax: ;,^ '>63 '�La 7� 00� . ' <br /> PROPERTY OWNER INFORMATION: <br /> Name: !'��^ �.� �^ <br /> Phone(day): <br /> A�ddress: 6 6( ..Scz� ,���i,�rC r���' City:�nsCix��'�6��a ZIP: <br /> Emait andlor Fax <br /> PROJECT INFORMATION: <br /> '1yp�oi ProJocf: My es�mo�ronNM mey roqulre <br /> MC1111D rwfe�w 8 p.rmks: <br /> �p�p��s� ❑Remodel ❑Wa�er Demage , NAinneheha Cr�eek Wa��shed Dishict(MCWD) <br /> �W��g� a Repe,;r ❑Storm Damega 18202 Minneoonka Blvd <br /> Deephsven,MN 55391 <br /> ❑Slding ❑Restoretion ❑Other:(specity) Phone: 952�71-0580 <br /> �e.roof ❑Fire Damaga Fex: 952�T1-0682 <br /> �_minnehah�creek.orc� <br /> Overall Pro ect D�crip�fon: <br /> Rstimated Consbuctbn Valuation of Pro�ct excludln land) S � � �cs� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> qgrees to provide aN infarmetlo�nequired or requesbad bY d�e 9uiWtr�DepartrneM; <br /> Certifies that me I�fom�adon supP�led is true alld correa Lo ths best of hislher krrowledge• The applkarrt recog�izes thet they <br /> are selely respo�s�ble for submlt6ng a comple�application being awere that upon failure to do sa,the stafF has no albamaUve <br /> bul to rejact it unbl it is oomplate; <br /> Some or all ot fhe information that y�ou are asked to pnovida on this sPpQation is dassifisd by State Iaw es eiihe�privete or <br /> cvMidernial. P�ive�� Is IMom�tlon vrhid�9enaral�canrrot be glvon�o the public but can bs plven to 1he subject af the <br /> data. Confid�tlal date �s Uf�o�matlon wF'I�h 9e►�erally cennot be given tn elther the public vr the subject of tha data. Our <br /> purpoee and inEended use of this IMom+atlon is m annu�ly updaGa our records snd records of ofher govemmer�l sgencies <br /> ulred law. If to s ifie lnfom�aUon the Icadon ms not be Issued. <br /> ApPlicant's Signature: <br /> �a�: y -�4=<< <br /> tAstuoe�ed: oa-o�-zot� <br />