Laserfiche WebLink
. . � C�� ���� <br /> �..��.� <br /> City of Orono <br /> Buildin Permit A lication for Internal Wo�� <br /> 9 pp <br /> (windows, doors, siding, re-roof, etc.) <br /> g O� Nt�Ht��: Permtt number. D - D 13 <br /> O Q C+Yslal Bay.MtJ 55323-OO6B Date recefved: <br /> S(reetAddtess: ���' <br /> z�so�ney�mw�y ��,re�ew ree: �'!� �� <br /> �te�,�o��� �rono,MN 55356 � • <br /> TotaPFee: �f��. <br /> Main: 952-249-q800 Fax: 952-249-4896 ?�w+w.cf-oror�gmn.� . <br /> This application form must be r,ompteted in tull and all requlred informatbn must be submikted. <br /> lr�omplete appllcations w�l be retumed. (Please pdnt) <br /> GEWERAL INFORMATtON: <br /> Job Site Addrass: s3.¢ �t-�.r[._,ra.Lt��'7e��tlt, �-a� �1.1 �'✓'3 � <br /> Wlil this be a Parade of Homes, Remodelers Showcase Hom or other Display Home? Yes No <br /> If ysu,a spacfaf eroerrt pBmrlt 1s►aq�hsd with Pb►!ce Deparimen7 and C(ty Cosmd►approvnf BO daYs Pr1or to Ure everrL ShWle!ws service w1C be <br /> iequWed untesa�cant demotrstrBtBs steRkyenf orTalte parkinB!s&va!leble. Nw+yetmNfed erents►vMi nof be eNawed. <br /> CaNTRACTOR/APPUCAM'iNFORMA7'fON: <br /> Name: i o �r� t��r�i{�►� -� '�t�`C�r' __ <br /> State Ucense# Expiration ate: <br /> Phone: o � �� <br /> Mailing Address: ity: _ ZIP: <br /> Contact Person: Appllcant�s: Contractor omeowner {c�►�o� <br /> Email andlor Fax: <br /> PROPERTY OWNER INFORMATION: CTic,+�1�'r� <br /> Name: G�,�„a1'4� �,�cr�t�lattll�'..z.�' �`s. �►�� <br /> Phone(day): <br /> E►adr�sr ��� g t��-�+-��-►�5 ��cv: � � Y;a ���►p. ��802 <br /> ErrsaSl andlor Fax i rw t f tr� n�r5c-c�-�"�rr� - <br /> PRO.lECT iNPORMATION: qny ear�n moverneM may requlre <br /> Type of ProJect: �1CWD revtew 8�Pertnita <br /> Q Door(s} �.Remodet ❑Water Damage <br /> Minnehaha Creek Watershed Distr9c�{MCWD) <br /> []Windaw(s) ❑Repair ❑Stcrm Damage 18202 Minnetonka B[vd <br /> Deephaven,MN 5539i <br /> ❑saane D riestorara.on L7 omer:is�ectry? Phone: 952-�471-0590 <br /> r-ax: s�-ar�-osa2 <br /> [�fie{oof C{Flre Damage Wtiyv�'.rninnetsals om <br /> Overall Pro)ect Descripdon: ��,! c�E�... O t � rll� <br /> Estimated Construction Valuation af Pro ect excludl lan � t p'S,_ �''�� <br /> APPLECANT ACKNOWLEDGEMENT: <br /> • Aprees to provide atl intormation requtred or requested by tha S�Idtnp Oeparbr►ent; ; <br /> • Cerilfles that the tnformat(on supplled is ttve and comect tfl the begt of hleJher knowled9e. The applic;ant recognizes that they <br /> are sdety res�onsible for submt�ing a oanplete appHcaflon befna aware ihat upon faNure lo do so.!he stafl has no altemffiive <br /> but io reJecx It unUi it is complete; <br /> • Sw�te or alf of lfte tnforrrraUon lhat you are asked to}xavlde on fhis apRlication ts dassif'ied by State Faw as ef�er private or <br /> confldential. Private data is infartrrallon wfifch generaNy carnwt be 8iven to the public but oan ba given to fhe subjed of fhe <br /> data. CflrtHdential data (s infom�ation wblfi generaRy cannot be elven ta eHher the pnbNc or the subjed of 1Fse data. Our <br /> purpose arid intended use of ihts iMotrnadoc�is W 8nnuatty update out►eoo►ds and reco�ds of other povemrnental agenaes <br /> re uired law. if u refuse to su ihe unorme bcat(on me noE be issued• <br /> Applicant's Signature: ��: 1��!/ <br /> ��. <br /> Last Updated: O:rO1-2009 <br /> f el2�tqa a1� 1 <br /> G�,Je�L�R oC _ �" �ac�.,a'l l _ 2.z� �/! <br /> i 'd T9T6 06b ZI9 tueCund btpes Q90 �OT TT 9Z UeC <br />