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l . , � � To� ! <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> � (windows, doors, sidin , re-roof, etc.) <br /> g O� ��' Permit number. oZ0/ � <br /> O O Crystel BsY.NM155323-0086 Date received: / <br /> � � Street Address: �by' — <br /> 2750 K�eNey ParkwaY Plen review fee: ?� <br /> Or�w.NM155356 <br /> Total Fee: JO�� <br /> M��; 952 24g.4gpp Fs�c 952-249-4616 www.ci.orono.mn.us <br /> This applk�atlo�fonn must be oomple�ed in fuM and aN required iMormaUon must be submitted. <br /> Incompisb�pik:stlons wiil bs roturnsd. (Please print) <br /> OENERAL INFORMATION: � � ���„�l�'1„_ � C�`� <br /> Job Sib Addnss: :,�i,�` T�"C, <br /> YVtll thb bs a Parad�at Hom�s.R�mod�l�rs Showcas�Homs or othK DlspUy Homs? Yss No <br /> by�s,a apecial e,�e„t psnr�la,rq,�lnd w�1,Adia�epransnt er,d c�ly Couv�al epp+vvs�eo doys pitor w d,e aver� Snwk bus asiv�oe wJn be <br /> rsq�uNed wde�a eppNcarK d�nons�ss iulBda�t on.ti6s psrla�Is a+Mab�e. Non�pem�NMd ewnts wIN r►ot be a�orred. <br /> CONTRACTOR I APPUCANT INFORMATION: � <br /> Name: /�1��6./lb�"- oOF� �'o�i �►'�OF� Li►� <br /> s�te��# - 2oar oa �� ExP�ra�on Date: D3/3� a o�a <br /> Lead Cerdflc�tlon Number: Expiration Date: <br /> (Ibr wak on honNs Lh�t wrn consbuc�prilw A�1� <br /> Phone: 76 3—�/a 7-q�q� c�� ?6 3 a8v-_ l3�_�__ _ c�u> <br /> Mailing Address: $' �dlr� �`f' CitY �A� vL ZIP: 3 6 Y <br /> CoMad Person: �n.y �G,SG.� Appikant is: / Homeowner �cra.a»� <br /> Email and/or Fax: ')63 — til�7� 4D0� <br /> PROPERTY OWNER INF TION: <br /> Name: �"i�Z Q�i/'h �/O�� <br /> Phone(day): / - <br /> Address: �( S fa✓'L CI��C�e City:�l�tC� ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> ��pro� My Wr1h mov�ma�t may nquin <br /> ❑poor(s) ❑Rertadsl ❑Wa�et Demape , YCYYD rovl�w�p�rndb: <br /> MMnehaha Cneek Wate�shed DisMd(MCWD) <br /> �yy�r�dow($� ❑Repeir ❑3�orm Darna�e 18202 NNnnetonlca Blvd <br /> p swi� O� D on,�r:(s�ah) �a�n,MN 55391 <br /> Ptwne: 952-471-0590 <br /> (�Re-roof ❑Flro Damage Fax: 952-471-0682 <br /> V� www.minnehahacreek.orn <br /> Ov�rall Pnoj�ct D�scriptlon: <br /> Estlma�sd Constructlon Valuatlon of Pro1�ct(exdudin�land) i Z6� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> ,qgross to provicls all iMormatlon rocWi�ed or reQuss�ed by fhe Building Departrnent: <br /> Certlfles that the intort�tion suppUed Is true and oorreCt to the best of hidher k�rledpe. The applfcsM recognizes that they <br /> are sobly r�ponsibls for submiqing a oomplste aPP�icatlon b�ng aware that upon f�lure to do so�the stsA has rw altemative <br /> but�reject it uM�it is oomple�s; <br /> Some or sY o�ths infcrtnatlon that you aro ssked to provide on tt�s applicatbn is dassi8ed by Stete law as eitt►er private or <br /> confidentlal. Private data is k�forrnatbn which gene�►cannot be given b�the public but can be given to the subject of the <br /> deta. ConlidenUed data is I�fortnaUon which �ene��Ny cennot be �ven �o either the public or U�e subject of the data. Our <br /> P��Pose and inbended use ot this ir�orrr�stfon ie to annuaUy updete our reoords and neoords oi other govemment� agenc�es <br /> uired law. If refuse to the informatbn the ma not be issued. <br /> APPlicenYs Signature: Date: �.� z —r' <br /> �.tupdao.d: 03o�-2ot� <br />