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� c� af orono �'
<br /> ty � � � � �� �
<br /> , Building P�ermit�plication for Ir�temal
<br /> (wir�cio�, doors, sidin9, r�-r�oo�, etc-)
<br /> �o� ^�►,,��- �►,�: aei -�o��a
<br /> � � p ca�aa,,, nnv�a�-ooes a��: � ��
<br /> .� � ,, �,a�.�: r�""�"�
<br /> ���98 Og�G~F Q'Of10, �.� PI�'1 f�Wf�:
<br /> ESH �_= Tatal Fee: �oZ�. 9
<br /> Nfain: 952 249-4600 � 952-24.9-4616 wrwv.d.orono,rm.us
<br /> This application form m�.st be oorrple#ed in full and all required inFormation rrx.ist be subrrrtted.
<br /> Irx�arplebe applications will be retumecl. (R'ease p�rirrt)
<br /> GB�2AL INFaRMAl10N: i�C�.
<br /> Job Sibe Addr+ess: ;_]�C� .S�n uc��w o�
<br /> Will this be a Parade aF Hares, Remodelers Horn�or otl�er Display Horr�e? ❑Yes �No
<br /> /f yes, a speda�evei�t penrrt is req��iied with f�ioe�tmer�t and CJty Co�uncil aq�av�60 days pia to the ewwrt. Slwttle bus seiwae will be
<br /> raquired uriless aqdicant derr�iates si�cierrt orrsite parldng is availaLYe. �brrp�enritted evei�ts will not be allaroeci
<br /> OONTRA�CTOR/APPLJCAPff INFOF�IVIAl10N:
<br /> rv�,e: �a�,�re� �,��Ide�s
<br /> State Voerise# a�0 6 3� �g� E�iration Date: 3 a�I a•
<br /> L�d Certification Nurri�er: _�- 18 3 1�-i U -U I 9 s� F�iration Dete: �c�- ��D I,r'
<br /> (fa'warlc an hanes Uiat we►e oarutructed p►ia'to 1978
<br /> Phone: (o�ioe) �.Sa- 2�Up- 3 93� c��)
<br /> Mailing Address: �lL} 12,'�9c�ne.s � D r�, �Y Gav��✓e,�, ZIP. S�.3!S
<br /> COftt��f501'1: ��r� L�Krel f�IG]flt IS: / w�ivauu � / HOf11EdW112f (QirdeOne)
<br /> ���
<br /> Erriail and/or Fax „,����e, �t..�.�e��a,�,�'Ide✓'s.GOw�
<br /> �
<br /> PROPFRTY OIM�Q2 INFOF�MAIION:
<br /> rvarne: �Tow. �- �hh 1`���.sov�
<br /> �c�r 9sa- 9i3 - 1'-� gb
<br /> �aa�: i-�a�v S�,�;,���..o�, �,d� c�tY bJ�,,��,-{�, aP �3 g�
<br /> Email arid/or Faoc
<br /> PFtQ1C�T IPFOF�l10N:
<br /> Type of Pr�oject: Arry eartl�rrtoverr�ertt may r+e�ir�e
<br /> MIL1lUD review 8�perrr�its:
<br /> ❑ 000r(s) G�r,ode� ❑v�cer oa�r,age n�r,r,er,ana aee�v�cetsr,ed asmcc�nnc,�>
<br /> ❑Wfncb�n+(s) ❑ FZ�r ❑ Storm D�n'�age 18'L02 Nimetor�lca Blvd
<br /> ❑ Siding ❑ F�Stora�ion ❑ Ottier.(s�ifY) ���,NN 55.391
<br /> Phone: 952�F71-0590
<br /> ❑ Fae-roaF ❑ Fine C�arriage F�c 96,2�71-0682
<br /> �nniwv.rrinr�hacxeek.orq
<br /> Overall Project Description: l�� r���-c��,,, cc.L, s �-- �
<br /> E�timabed Cor��ction Valua�on aF Project(e�acludin9�� a �D r�
<br /> APPLJCAIY�A
<br /> • Agees to praride all inforrrr�on req�ired or requested by the Buildn9 Depertrnent:
<br /> • Certifies tha�the inForrr�tion supplied is true and oorred to the best c�f hislf�er'Ivio�ndecicje. The applic�rd reoograes tMat they
<br /> are solely resporisible for s�nitting a corrplE#e applicabon being a�n�ere ttrat upon failue to do so,the sraff has no aftemative
<br /> but to rejed it until it is oorrplete;
<br /> • Sorrie or all oF the inforrr�on tl�at you are asked to pr�ovide on this applicadon is dassified by State law as e.ither priva�e or
<br /> oor�ide�ial. Private da�a is ir�iOrrr�on which generally cav�at be gven to the public but can be gven to the s�ject af the
<br /> data. C'.a�fidential data is infom�on wtich g�r�erally�r�d be�n to either the p�lic or the s�ject o#the ciaha. Our
<br /> pilpose and intended use of this ir�fom�on is to arxx.ially i{�date ar reooRis and reoords af ather gau�rnrr�rtal agencies
<br /> 'red law. If refi�seto the inforn'�on,lhe icabon r�t be issYaed.
<br /> ApplicanYs Signature: ��"'- Diate: ���� l�
<br /> �ast upaated: 03-o�-2oi i
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