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�Sy3 � <br /> � � City of Orono <br /> � 6uilding Permit Application for Internal Work <br /> ' (wfndows, doors, siding, r�e-roof, etc.) <br /> ����� Permit number. ��'�"` � � <br /> O•g,O,�O Po eox ss <br /> Crystel Bey,MN 55323-006e Date reoelved: � <br /> Slreet Addreaa: R�"�bY: <br /> � � 2750 KeYey PerkwaY Plan revlew fae: <br /> Orono,MN 55356 <br /> Main: 852 248�4600 Fax: 952 249�616 .ci. ron . .0 T�F�� �O" ' D� <br /> This application lorm must be oompleted In fuq and all required Inf�ornnation must be submitted. <br /> I�comp�te applkatlons wlll be returned. (Please prin� <br /> GENERAL INFORMATION: � /�, t_ <br /> Job Slb Addross: (,/v'L <br /> YVIII tfils be a Parado of Homos.Remodol�rs Showc�se Home or athe�Dlsplay Honw� Yes No <br /> K yss,a spedld event psnnk Is rsq�dnd wrltl,PaUce�spsransne and cky cormcN aqpova�60 dsya ybr m d+e swne. Shume bus ae�v+oe w��be <br /> �►ed u�k8t ep�Wosnt de►r,a�nsaares aulllderu on,s�e ve�Jdn9ls av�ab�fe. Non�enn�ted evanfs w�l not be aaowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Nerne: /�1;�w15� ��o�,7� 5��� !,✓��IdoFd L�c <br /> State Liaense# 2�v��a �� Expiration Dete: �3/31��0�� <br /> Le�d Cefification Number: Expiretion Date: <br /> rybr wwk a�homss that w�sre conshuc,Js�prbr b�l7d <br /> pt►one: 76 3—�l a? 7-��e q� c�� ?6 3�180—� l3� � c�n� <br /> nnsnin�Aaaress: ' S S Ga c1- cit�►: a�,��-� ziP: S3 6 4 <br /> Contact Person: /�y�� �f�G.^ Applicant is: n r I Homeovmer �c�.o�.� <br /> Finail Bnd/Or Fax: ' <br /> '�63 -- y ��- 9ov� <br /> PROPERTY OWNER INFORMATION: <br /> Name: .S'�e✓�� /�p�1 u�► <br /> Phone(day): <br /> Address: _�,(o St�.,�dS�C ir. City: Lp,��ikc�• ZIP: <br /> Emad and/or Fax <br /> PROJECT INFORMATlON: <br /> Ty�af ProJ�ct: My�arth movemeM may requlre <br /> � ❑Door(s) ❑Remodel ❑Weter Dem�e , MCWD ewl�w 8 psnnfts: <br /> NUnnehehe Creek Wetershed Distric�(MCWD) <br /> ❑WL�dow(s) ❑RepaU ❑Storm Damage �6202 Mi�nemMca B1vd <br /> ❑Siding ❑Restordtion ❑plhsr.(speciy) �phaven,MN 55391 <br /> Phone: 952�471-0590 <br /> [�Re-roof ❑Flre Demege Fax: 952-411-0682 <br /> www.minn�hahacreek.am <br /> Overall Project Descriptlon: <br /> Esdms�ed Constr�w�lion Valuation of Project(excluding la�d) S �ra <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agrees m provide a11 iManriatian required o�requested by the 6uiaing Departmer� <br /> Cerdfies that ihe infom�ion suppGed is true and correct to the best of hfs/her kno�Nedge. The applicant rscogni�es that they <br /> are sololy responalble(o�submNdng e oanple�e epplketlon being aware that upon failure to do so,the atalf hes no altemative <br /> but to reject it undl it is complete; <br /> Some or all ot the iniormadon tl�at you are ssked to provide on this application is daesifled by State law as either priva6o or <br /> coMidential. Priwdde deta Is�fo�matlon whlch generally cennot De ghren b tl�e pudic but cen be yiven to ihe sub�ect of the <br /> dsta. Co�identis! data is in(vrmadon which yanerally cannat be given to el�►er the pubik or the subject of ihe daCa. Our <br /> pu�pose end InterMed use of thls iMarmativn is to ennually update our reoorde e�d reoords of other gov�errYnenl� egenaes <br /> uired lew. If refuee to su the brFormsfion the a icabon ma not be iasued. <br /> ApplicanCs Signature: pate: �"�—�� <br /> I.a6t Updeeed_ 03-01-Z011 <br />