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� <br /> " ^ City of qrono <br /> Bullding Permit Application fo� Internal Wo�k <br /> ' (windows, doors, slding, re-roof, etc. <br /> ,¢Q� �u���' Pormlt number: / —DO � <br /> Q � CMB�I BaY.MN 35323-006C Dste�ece�ved: / <br /> a� � Street Address: ��bY: <br /> '� 2750 KeUey Parkway Plan review fea: <br /> Orono.MN 55356 <br /> Totel Fes: ��'��� <br /> Maln: 952 248-4800 Fax: 952-248-4818 www,ci.orona.mn.us <br /> Thls appllcation fiorm must be completed in FuA and aU required Infwmation must be submittad. <br /> Inoomplo�a applications wlll be retumed. (Plesse print) <br /> GENERAL INFORMATION; '1 S''� Li(/! <br /> Job Site Address: <br /> YVlII thls bo a Psrade of Homes�Rsrnodsiers Showcase Home o�other Dlsplay Homs? Yas No <br /> Ifr.s.e apede�everitper,nn Is rsqW,ed waErr Pol�e oepa�vn�ne and ciq�councr eppvva�Bo dars v�ar�b rhe evenr, snumda�we soiwoe wA�be <br /> �eqw►ed rwless�demons6atos sid�t on.�7e paildng!s awa�eb�e. Non-pen►�fted ev�ents r�not be eUowed. <br /> CONTRACTOR/APPUCANT INFORMATION: �/ <br /> Name: /��d Wl$7''- Om . �a/ !�'�0� L�C <br /> State Lioense# 2 0 oi o a �� Expiration Oate: p3/3/ <br /> �Ot� <br /> lead Cerlific�tion Numba�: Expiretion pate: <br /> �w worAr on hamos�hst ws►e constr�p�1a►1n 1878 <br /> Phone: 76 3—�/� 7`q G9� co�) 76 3 0180- l3 � cceu� <br /> Mailing Address: � S CQh4�� Cf' Cfty: ��ll� irc- zIP: 3 4' <br /> Contact Person: �ti� �p,sG n Applicant is: n / Homeovmer �ca�.a„� <br /> Email end/or Fax: 7(,3 ... y ��� jQ p/ <br /> PRQpERTY OWNER INFORMATION: <br /> Name: �,�n��. /��y� <br /> Phone(day): _ _ - � , <br /> Addr6Ss: ��_SC�rw�STon G C ir Clty: ���L�� ZIP• <br /> EmaR and/or Fax <br /> PROJECT INFORMATION: <br /> Typs of ProJect: My eorth moremont itw <br /> ❑Door(s) ❑Remadel ❑Webar Derr�ege , MCYW revlew b pennlb ulre <br /> ❑Window(s) ❑Repair Minnehaha C�eek Wetershed District(MCWD) <br /> ❑S���� 18202 MMnetonke Blvd <br /> ❑Sidln9 ❑ResWratlon ❑Olher_(spedfy) pp p�� 852-471-0590 <br /> [�Re-rooi ❑Fire Damage Fax: 952�7t-0682 <br /> wvwv.mir�r�9h8hacreek.orc� ___ _ <br /> Overall Projeat Daacrlpqon: <br /> Estlmated Conseructlon Valuation of Pro�eet(excludin8land) , S '� �, <br /> APP�ICANT ACKNOWLEDGEMENT: <br /> Agrems to provida sll informefion required vr requeeted by tl�8uilding Departmenk <br /> Certifies that the iniomiatfon eupptied is true and correct m the best of hislher knowiedge. The appNcant reoogni=ss that they <br /> ere solsly responalble for submitting a compleoe applicapon befng avrare that upon fadure to do so, I�e statf has no albemadve <br /> but bo roJect It urrtll it is complate; <br /> Some or eq cf the ininrmetlon thet you are askod co provide on�his applk�tion is dessMed by State law ss eitha�private or <br /> confideniial. Pmreee datia is miormatlon whlch gonerslly cannot be pivoc�to the public but can be viven Go the subjed of the <br /> dete. CcMidential data Is Informsdo� whid� gen�Ay cannot be glven to aithe�the public or the su6Ject of the dats. Our <br /> purpose end Intended use oI this I�Normation ie to annusly u�our reco�ds and records of other govemmentel egencies <br /> uired b law. It u to su tl�infom�atbn {he ' n me not be i�ued. <br /> A►PPIIcanYs Signature: "� Date: � di ` �r <br /> Lost Updailsd: 03-01-2011 <br />