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Oct-2T-2010 11:04am From-CITY OF ORONO +9512494616 T-588 P.002/002 F-B53 <br /> v��� v� v�v��v <br /> - Building Permit Application for Inte�nal Work <br /> � (windows. doors, sidin , r�-roof, etc. <br /> ��.�,�0 M�PO Bo�B� . Permit riumbe� •Q�� <br /> � Crystal Bsy,MN 55323•0088 Date�ee:eived: /� <br /> � .`� 3hest Address.' RCcelved by: <br /> . 2750 K�Uoy Parkwa <br /> � Orpno,MN 55358 y P�����' <br /> ��Foo: �'�a,�aa <br /> Main: 85�-2q9-�800 Fax: �52-249�4616 �pppp�,��,Qrono.mn.ua <br /> This applicatlen torm must be completied in fLll and all required informetion mus! be submitted. <br /> Incompl�ts spplications wUl be retumed. (Piea�e print) <br /> GENERAL INFORMATION: � `- _ � �� <br /> Job$ite Add�ass: rW�p�� <br /> Will this be e Parade of Hornes, Remodeler�Showca Homa or oth�r Dispiey H�me7 Yeo No <br /> Mya�s,e apeNa!evsnt psirrbt b roqvpsd wiM�polfes D�penr»ent anG Cl�Co�mdl spp�ovs180 deys pnor b His eronl. Shuffilr Ova asAAdos will be <br /> rsq�Jisd unfsss spplTcant cfs►nonsnefes sWlicNnt�tib perkMg N evaNsbls. Alon-psrmitAed erenta wIN not bo eYpw�tl. <br /> cONTRACTOR I APPLICANT INFORMaTIQN: <br /> �^�� Renewal By Aade�sen <br /> stete L�cense# 1920 Couaty R.oad "C" West Expiration Date: <br /> Phone; Rosevil.le, MN 55113 ���� <br /> Mailing Address: L;cense #20130983 �'H= ZIP� <br /> Contect Person: d is: Contrecror / HcmeoNmsr K�Ra o�y <br /> Email and/or Fax: 651-264-�777 <br /> PROPElITY OWNER 1 OR ATION: � ; l�r <br /> Name: <br /> Phone(day): <br /> Address: 'S� C' � ZIP: <br /> Ernail and�or Fax <br /> PROJECT INFORMA'rION: <br /> TYP�°�PfO1°a� Any sa�th meven�� m�y�aquiro <br /> MCWb roviOw&p�►mib <br /> ❑Door(s) ❑ Remodel ❑Water damape <br /> ❑Window(s) O Repair Minneh�ha Craek Waterehed Diatrict(MCWD) <br /> ❑Storm Damage 18202 Minnctonka Blvd <br /> D�epheve�,MN 58391 <br /> [j Sidi�9 ❑ Re9toretioh ❑Other:(speciy) phone: 852�71-0590 <br /> ❑Re-roof []Fire Damage �ax: 952-471-0682 <br /> Overill Pro ect Description: 1 QpY �yV •Q/�i-S� � <br /> Estim�led constructicn Voluatio of p ect exciu in IanO t D — <br /> APPLtCANT ACKNOWLEDGEMENT: ' <br /> • l�graes to pr�vide alt inrormatfon requirad or requeStea by the Bullding DepaRmeM: <br /> � Certffies thpt the fMormatlon supplied is true and oonect to the best ai hfs/hsr knowiedge. The eppGcaM reoognizes that Ilfey <br /> are colely respansible for eubniitting a oomp�ete applicetlon being eware thet upon isilu�s to tlo so, the sfafF has no ahemetive <br /> but to reject It unttl it is oomplete; <br /> • 3orn� pr all of the Inforrhepon that you are askad to provide o� fhle epplication is dessified by 9tate law a6 elih9r private or <br /> conhdeMial_ Prlvate da�a IQ iMormnti�n which generely t�nn� be gi�en to 1he publk but cert bo giren to Ihe subJaG �t the <br /> data. Confldentisal tlsta is inbmtetlon whiCh g�ner�lly cannot be glven to either the public or tha subJed of 1he date. Our <br /> purpcse and iMended use of tht8 i�ormahon is to annuetly update our recorde and reco�ds el other governmental agencies <br /> ired b law. I! o�reEuse to s I ihe(niormstlon ti�e e icatlon Rre na be 18susd, <br /> o►pp��cant's Signature: bate: ��-Q ��b <br /> �a�tupnes�a� a�-o.-2ooa <br /> Z •d 06T9�L9T59 3�IA213S lIW2l3d Q R S A SZ =6 OTOZ L2 ��O <br />