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10/12/2009 15:07 9524738680 DALBEC ROOFING PAGE 02103 <br /> ' ' � II� <br /> � <br /> City of Orona <br /> B�ilding Per It Applica�ion for Internal Wa►rk <br /> � (windo s, doors, siding, re-roof, etc.) <br /> MaiUn�Address: Permit number. ` ' -� <br /> .�0� ' P Box 66 ' ' 1 D <br /> O 0 ' C stal Bay, MN 55323-0066 17ate received: !. : 1�,3 <br /> � Street dd►ess: Recelved by= �;� <br /> � �� ' 2 50 Kelley Parlcway . ' <br /> ���� O no, MN 55356 � ; <br /> —_ ! Total Fee: � <br /> Mai�: 9�2-249�600 Fax; 52-24�-4616 www.ci.oron .mn.us � i �7��Z <br /> This application form must b�completed in full and all required infoRnation must be submitted. <br /> i ! Incomple applicatlons will be retumed. (P/ease printJ <br /> GENERAL INFOR�VIATION; <br /> Jpb Sot�e Address� � , , <br /> 1IYII this,be a Parade of Nomes, Remodelers Showcase Home or other Display Home? ; � Yes o <br /> !I yYs,8 SpeCi6/AVBIII peRn/f IS/equlrsd wfth Pvli�.z DeNa�tmant dnd City Counci!oppro�ol 60 doys prior M tho avwit. ShEift�Q huc ar3rvice Will bA <br /> requlred�nless applicanf demanstrat�s sutficient on-site paRcing Is available, Non�ennitted events wlll nol�be allowed. <br /> CONTRACTOR I APPUCANT INFORMA I�N: <br /> Name: �L � ' ' <br /> State License# ' �b 83 Expiration Date: �;�SJ-/o <br /> PFwne: �-47�-�AB� offic� /J- -/3/ Cell <br /> Malling Address: Sr Ci : LaN (� , ZIP: 3� <br /> Contact Person_ __�L�c ��E 12 I Applicant is: ontracto / Homeowne� �ci�e o�a� <br /> Email and/or FaX: r .c� d-4 � <br /> PROPERTY OWN��i INFORMATIONc ' � <br /> N�me: (N 1� n ' ; <br /> Phone(day)� S - - `��"` <br /> A�dress� tt� �'- �,(�l'L I � ZIP: �42�' _ <br /> Er�ail andlor Fax �A I � �� n G� �� — <br /> � ; ��p �, <br /> PROJECT INFORr111ATION: � Q�'I� �, O�J n� <br /> Type of Project: � I � �, , nt may require <br /> j S� _ � � � �penmlts <br /> ❑Door(s) ❑RemvWdl � <br /> �Y� � � Q l��� �d District(MCWD) <br /> ❑Window(s) ❑ Repair [ � `( a Blvd <br /> ��p r'�' n � ,5'i91 <br /> ❑Siding <br /> ❑Restoration ❑ �f " `�� 1580 <br /> �, g2 <br /> e-roof � 0 Fir�Damage � '<_orc� <br /> Overall Project De�cription: �, p �yt <br /> Estlmated Construbtion V8luation of Prb)ect(exclu � � <br /> � �� � <br /> APPLICANT ACK�IOWLEDG�MENT: <br /> - Agroas to pro�ido�II information requl d or raquPetPh ,, <br /> • Cert�fes that the information supplied �s true and carre .,,�ner knowledge_ The appli�cant recognizes that they <br /> are solely resbonsible for submitting a complete applica _„�g aware that upon failure to do so,!tl`1e staff has no altemative <br /> but to re�ect it�uniu it is complete; i ; <br /> . Some or all di the information that yo are asked to provide on this application is classlfied by St�tle law es either private or <br /> confidential. hnvata dot� is infortnati�n which �?nerally rannot be given to the public but can be'dven to the subJect af the <br /> data. Confid�ntial data is Infortnetior� which generally cannot be given to either the public or th�: 5ubject of the data. Our <br /> purpose and intended use of this inf rmation is to annually updete our records and recarcJs of othbr governmental agenGes <br /> rw.uirwd b I.aw If �u rPfii�in cu I the information the e I� i n ma not be Issued. �,�, <br /> � �' ' I <br /> ApplicanYs Signatu��: r Date: f!3 �1 a-o� <br /> � <br /> Last Updated: 05-Oa-2009 <br />