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� >�. Q���O� � <br /> City of Orono <br /> Building Pen»it Application for Internal Woirk <br /> � � windovirs, doors, sidi�g, re-roo�f, etc.) <br /> �O A' ��' Permit�umber: o�U//—0 U <br /> 0 `rp crys�a aey.�ss32s-0oes oate re��rea: <br /> � � sbeer�anrar�: �"re`��'� ' `' <br /> 275o KeNay Parkwar Plan rev�a�w fee: <br /> Orono,MN 55356 <br /> . ra�F�: � /D.�05 <br /> Mefn• 852�49-4600 Fa�c: 952-248�06�6 v�nry�-�i.oro�o.mn.us <br /> This applkx�tion iorm must be oon�pls�sd in fuR and sR requfrred infrnrnation must be submlKed. <br /> Incomple�s applkstlons w111 b�retumsd. (P/eas+s printJ <br /> GENERAL INFORMATION: *"` (Q �"' _,,,���� / .,�� rP <br /> Job Slb Addr�ss: / �+'1�' 1.., <br /> WIII thl�bs a Pared�of F�an.s�R�modoMrs Showcass liomo or ott�Dbplay Homs? Yos No <br /> Krr,a epeale►ewr�r prvrdr Is i.qu�red w�n Pallo.G�rone+�t e►d Cb►Cound�pproval 6o d�C ab►ro uie 6re►u. shums hua as►�loa w�he <br /> requln9d IN�ssa a10��demontb6Ms a1d14��nt an.e�pe►Id�p tt ewsNsb�e. �evenfs w�nat Oe eA�owed. <br /> CONTRACTOR/APPUC�T INFORMATION: <br /> Name: /I�i(l f�✓�S� 001�� S�/ d�A7i�0(� LnC .� <br /> �a���# �aao�oa �� ��, o�: p3/3i �o�a <br /> Lead Certiflcatbn Number: Expir�tbn Date: <br /> �Ira wwk on bonws�t waa vanson�IiHor do t! � <br /> Phone: 76 3—�+lo� 7-q�'9� c�) 76 3 0180- l3� � c�u� <br /> Meiling Ad�+ess: $ C`r - CItY: �t vG ZIP: —3 6 <br /> Contect Person: �ti` ��4•� Applic�r�t is: / Nomeowner �cra.o�.� <br /> Email and/or Fax: '�63 — N a 7~ �00/ _,� <br /> PROPERTY OWNER INFO TI N: C< <br /> NaR18: � �n/�r.�2.7 _.,.._ <br /> Phon�(day): � /_ . <br /> Address: " -7l 4 Sa� Sfv�c ��ZG� ��hr L�'�19�1�G zIP: w.__._ <br /> Emad and/or Fax <br /> PRaECT INFo�u►nON: �, <br /> Typs of ProJsat: Any w�d�mowm�nt may nqu�n <br /> ❑000r(s) O aa,ioae� ❑wa�er asmege _ ��a perm�d: <br /> Mlnneh�ha Creek Wa�ershed Dlsbkt(MCwD) <br /> �yyindow(s) Q Repair ❑Stonn Damepe 18202 Minn�onka 6hrd <br /> ❑Siding ❑Rssbastion ❑Otlter:(mpsdijl) �ePha�en.MN 55391 <br /> Phone: 952-471-0590 <br /> p� Fe� 952�71-0BB2 <br /> ❑��F ❑ �D� www.minnehaha�re�k.orq _. � <br /> OveraU ProJsce D�scM n: <br /> Esan�abd Comtivctlon Valuatba of ProJs�t(�ccludlnp Isnd) : � .:� <br /> APPI.ICANT ACKNOWLEDGEMENT: <br /> qprees�provide aM iMatmstion requlrod or requeatad by Ihe Buddirg DopeKmo� <br /> Ce�fii'�es that�e ir�forn�adon supdied k aus and oornea a Ihe best of�IrJher knowledge. The appNcau�t raoopnizes thet they <br /> er+p solely respensible for submiqillg a oompbbe aPD�i�tiOn bei�9 aw�ue thal upon failure to do so,tho sFe1f has no al�omeUve <br /> bul to reject it ur�l h ls�e; i <br /> Some or ell aF the hffa�r�ation MaR y�ou aro asloed�o p�vvide �thlo epplicetion is�ed by Stsbe law ss either private or ( <br /> �nfidenbal, prlyate ci� is 4�Onna�on whlc�9eneraNy cenrat be given oo the public bul wn be given oo Ihe subjed of the � <br /> ��. ���ntlal de� � hio�metlon Wtddt genaslly camat ba gi�ren �o elthe�the publ'�c or the subject of the Cata. Our <br /> pumose and {nOsnded use cf fhis inbnrmtlon is�o snrx�ally updeba our reoords and rec�nds of oMe��ov+emme�l agencies I <br /> u' law. If re(i+ae�o s the inrormation Ihe a ' m� not bs iasued. <br /> p►PPUcant's Slgrreture: � � Date: <br /> ,,��.,�'��/ <br /> �as u�od: os�-zo�� <br />