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. . . � ��� <br /> City of �rono <br /> � Building Permit Application fo� Inter�nal Work <br /> • windows, doors, siding, re-roof, etc.) <br /> Meiun9 Address: PermR�umber y <br /> O�0�O PO Baoc 66 � <br /> Crystel Bsy.MN 55329-006B Debe received: <br /> Sheet Addreas: Received by: <br /> � � 2750 Kelley Parlcway Plan revlew foe: <br /> � Orono.MN 55356 /D�� <br /> Totel Fae: <br /> N�i�_ �2.24g�t6pp Fa�c 952-248�4616 www.ci.orono.mn.us <br /> Thls application form must be Comple�ed In fud and all required ir�forrnat�n must be submitted. <br /> Incomplote applit�ions will retumed. (Please print) <br /> GENERAL INFORMATION: �°„_,�,�. GI�� <br /> Jab Site A�ddress: �� •'i'"'u - <br /> Wlil thls ba a Pa�af H��nes.Remodelers Shovvcase Home or other Di�play Home? Yes ❑ No <br /> K�a speae�eve.0 venn�r is ievuNd w�N poHce Dsp�rn�nt and cky counal aaa��d����� ���e�^"��►� <br /> roqwred unlsss epipGcent demnnsbatea aullkk►d a+�alt�P�Idn9 is eve�ebls. Mon�pe►mMed eirerRs w�not bs aAowad <br /> COWTRACTOR/APP61C T INFORMATION: sr�� ��d�� Ln� <br /> Name: /�'��W��� �00���h9 � � <br /> State License# t?O/p 7 7 Expfratfon Date: p3t 3� ��ra,_ <br /> Lead CaNflcadon Number: Expirapon Date: <br /> pbr rwrk on hane�s tlwt oons�n�c�l l�lvr b 7978 <br /> Phone: �b 3�ra �"q�q� co�, 76 3 a1�'v— 3� � c���, <br /> Mailing A4dress: S' S r'+-a' <br /> L'�f- `i�. ��� (/r.r ZIP. �,�V� <br /> CorKact Person: �r�� �PiSG n ApPlicarrt is: ctor / HOmeowner �crd.o�.► <br /> Emall and/or Fax: 63 -- " � <br /> PROPERTY OWNER INFORMATION: <br /> Nsme- � �'nL .�Uh�{.S. <br /> Phone(day): <br /> Address- �17 Sa nd St'�"� ,/. C"�ty: Lpr�(f� k-t ZIP: <br /> Emav andlor Fax <br /> PRO.IECT INFORMAl10N: pny��,movemoM may requiro �I <br /> Typo of ProJeet: YCWD rsvi�rr 8 psn+�its: <br /> ❑Doo►(s) ❑Remodel ❑Wster Da�nape , ►y�nnehaha Creek Watershed D'�strict(M(7WD) <br /> �yy���(8) ❑Repair ❑Stom'�Demaye 18202 Minnebonka Blvd <br /> � p �� Deephaven,MN 55391 <br /> ❑Siding ❑Restorebon ❑Ol�er. s e Pho�e: 952�471-0590 <br /> @�Re-roof ❑F�re Dsmsge Fax: B52-a71-0B82 <br /> www,minnehahaCreAk.o_,gr <br /> Ovsrall Pro set Descri on: <br /> �m����ya�ua4�o�of pro'ect �xcludln land s <br /> APPLICANT ACKNOWLEDGEMENT: <br /> ,qgreee to pravide�I informatlon required or roques�ed by the Building Depanman� <br /> Cerdfles thet tl�e IMo�mation suppped is Vue arxi corred bo the best af hisTher knowledge. The sPP��re�8nizes V�at they <br /> are solely respons�le for submittlrg a comple�e epplic�tbn bei�awero thst upon failu��do so.the stsff has no allemative <br /> but to reject it urrtil it is compbto; <br /> � Soma or all ot�e infarmetlon that you are asked to provfde on this appllCa6o� is daesified by Stete taw as elther privste or <br /> co�+i'ideMlal. Privs�e data ls informaqon wh�cF►9ene�NY��t be gMen to tlte public but can be given to the su�of the <br /> dats. Co�idanUal data ls IMomia�on which generaAY ca�^�t be 9�� � a���e public or the subject of the deta. Our <br /> pu�pOso and inbendad use of U�is infom�e�cn is to ennually updabe au� reoords and records of othar govemmental agendes <br /> ui b law. If u reiuse b� d�e iMortnetion the dan cwt k�e lssued. <br /> � �%��� ' '_'�) `o� r�( <br /> Applicsr�t's Signaiure: — p�: <br /> —�,. <br /> Leet UP��: 03-01-2011 <br />