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Feb081109;18a MERRITTRESTqRATION 3039538985 p,1
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<br /> . � � City af Orono . � '
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<br /> � . ��uilding Permit Ap�plication for Internal Wor�c � `
<br /> � tw��t�dQws, d�oors, siding, re-roof, et�.) .
<br /> I�ellir�gAddress: �=�'a�rrii��n�4er'.'::�: '.��� '
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<br /> Q Crystal Bay, MN 55323-OOB6 `�Datei�eceitied .-`�.��...�'�.�`�`-;:`.:'%��:'-' .
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<br /> ,� � sa�ra�a►�ss: �,.,�eo��oea�y;�"::;�:i .: - ,. : �::� ��� � -
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<br /> � 2750 Kelley Parktivay .�Pla rs� � �-`''�:Y.��;::�.,��"j�'��
<br /> � Orono,MN 55358 �� �1���•.:;.' -� :�.. .
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<br /> ' 36:181,'Fe `: ';.� .�::.;' ,:._�
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<br /> FeX: 052-249-�B16 -:'�.,,�.�.�•�`;>.,�'�''ha-i
<br /> Main: 952-245-4600 www.c�,;orono.mn.ue '�}-:��.;�` - - �_: ,��:;...--,:;�;r,,...
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<br /> This applica�n farm must be oompleted in full and all reQu�r-ed (nforma�ion must i�e sUbmitted. '
<br /> ` {ncorn�[etie applicaf3ans wlb!be returned. {Pleese print) :
<br /> GEN�RA INFORMA�TION:��CD��L� fo���� �r �D ��' !✓3 C�
<br /> Job $ite ress: �7 /� Q J �7
<br /> Will this b �Parac� of Hontes, Remodelers Showcase Home or other Display Home? Yes No
<br /> lf yrea,a s,Recfel ewant permlt!s►eq�rfied wt�Poh'ce Departa�erM and Ci'ty Cow�dl a�ovel BD deys pnor to fhe event ShuGls(xes seFvfce vylA'be
<br /> requirad unless eppUcsn!damongUates sufRdanf an�slle parlafng�s avadable. Novrrpermltted everrts w(8 not be�fowed. �
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<br /> CON RACTOR!I�PT�ICANT INFORIWIATI . �/O� �
<br /> Na
<br /> ( Sta Lic�nse# E�iralion Date: �-3� �OIZ -
<br /> Pf�w�e: office oell
<br /> Mailing Addre : � C : IP: S
<br /> Corrtact Perso : i G � ' Applicant Is: on or / vmeawner �cfrraaonel
<br /> Ema�andlor Fa�c: .G
<br /> PROPER WNER INFORMWTION:
<br /> Nsrne: — �
<br /> � Phone (day): � Q
<br /> Addr+ess: C' D!1 ZIP: Jr�3s�i
<br /> Emaii arrd�or ax ' .
<br /> PROJECT F(3R�Ai4TJON:
<br /> T �p Any earth movementmay require
<br /> y� - � MCVIID review 8 peFmita �
<br /> ❑Door(s) Remodel ❑Waber Damage ' � ' '
<br /> Mi�nehaha C�ee1c Watershed Diat�ict(MCVWO)
<br /> - �'�fVindow(s� Rep�lr . ❑S'form Damage 18202 MEnnatoraka Sivd
<br /> Deepl�►aven,MN 55351
<br /> ❑S{�ing Restoraaon ❑ane�: �specit� Phone: 952-471-0�80
<br /> Fax: 952-071-0682
<br /> ❑R�.roof Fre Darna e vu�w�nF.minnehahacreek.a'`fl
<br /> O�erall Proj ct Dascrlptbn; - ` � G�f/ S
<br /> EsEimated C nstruation Yaluatian t�Project�excludin land � IO . -
<br /> APPL CAN ACKNOW DG�EMENT:
<br /> • !tg bo prvvide�aA intormatbn required�or requested by the Siiilding �epa�nent;
<br /> • Ce�i'i tf�at the iniormatlo�supplied is ttue a�d correct to ihe best of hfs/her knowled�e. l�e applicent recognizes that they
<br /> are a ly responsible for submittirtg a oomplete epptica�on being awars that upon feilura to do sa,the statf h�no alterrtative
<br /> b�to ject it until i is canplete;
<br /> • Some r all of the formaiion Ihat you are asked to pro++ide an ihis�eppl�Cation is classified by 8tate law as eithec private or
<br /> cor�d tial, Prlv data is information whlch generafly ca�ot be given to the{wblic but can be 8iven to the subject of tf�e
<br /> daCa, onfidenttal data is irzFormation which 8enerally carmot be glven to eitl-i�1�e public or the subjeot of the d�a. Our
<br /> p�rp anci tnbended use of Ehis information is to a�nually vpdate our r8ca�da and records of other governmental agendes
<br /> re �f b law. If �refuse ta su the information the a Gcadom m �ot be issued.
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<br /> Ap�licant's Si na�t�ue: � Date: � v �!�
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<br /> ��t updac�: o oos �
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