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Dac-18-2011 12:28pn From-CITY OF ORONO +A5224A4616 T-344 P.002/002 F-A73 <br /> �r��� v� v�v��v <br /> . � Building Pe�mit Application for Internal Work <br /> (windows, doors, sidin , re-roof, etc.� <br /> � �enrn�Aadrees: <br /> Po 9ox Bs Pernwt n�mber. <br /> O p cryBeai a�,MN 66323-0088 oats rocaved: <br /> � '� � Sfroet Ad�sa� ReGYIvAd Dy: <br /> � 2�60 Kelley Pa�ltw�y <br /> � od' Orono, MN b5356 p�e^��� <br /> Maln: 652-24�-4600 Fax: 852•24g•qB TO�F�': '/ p� <br /> 16 ° �O, �� <br /> This applicatldn fnrm must be comple�ed in full and ail�equired informatJon muet be avbmitted. <br /> Ineanpfot�applicaUona yWll be returnsd. (P/aese pnrry <br /> GENERAL INFORMATION:�I�O �., ' <br /> Job Site Address: N <br /> Win this be e Parade of i-iom�, Remodelers Shawr.ase Home cr othe�Display Home? Yes Wo <br /> I/J^�s.e spsGN�wntOe►mlt Is bpui�sd w/tt►PbUa�C�paefmsnt snd Ci�y COuncN.pProw/60 daya Wto/10 tl�a a�erM, ShuMM bus aavbs wDl b� <br /> nQui�sd uM�st sP�lkAnt deirioP►6trAlss euNFasnf on-sila parkMp is svolla4l�. Na►l�e�n�led�venh wIN no1 Ee aaowsd. <br /> CON7'RACTOR I APPLICANT tNFORMATIQN: <br /> Name: Kenewa�tiy Andersen <br /> 3tete License# ` 1gz0 County Road "C"West Expiraaon �ate: <br /> Phone: �' �o�vi2�e,MN 55113 <br /> Med�g A�d�e. License#BC130983 Ct : Z�P; ceu <br /> CoMaCt Per�pn: —" t is: Contractor / Homeowner <br /> Email andlor Fax: � 651-264-4777 �C�ero o�n <br /> . . .. _ .. .�........�.. <br /> PROPERTY OWNEFi INFORMA O : <br /> Neme: �,r <br /> P�lOf16(d8y�: .. r <br /> Address: � , <br /> Emalf end/or Fax . z�P: <br /> ._.... ...._ <br /> PROJECT INFORMATION: � - � �• . <br /> Type of Pro�s�t: <br /> , �. M!I Mrlft mov�ement may�quiro <br /> f]boor�s) p Remode► ❑Wafer Damege �WO rrvle�r d pannits... - <br /> '�I1Mndow(e).,.,. . . ❑RePair p Sronn oamage Minneheha 8�alc�neeonka 8 d��MCVW) <br /> []Siding p Reatoretion ( ��) DeeDhpven,MN '55991 <br /> .. . . ❑Othe�: e Phone: 952-471-05QD... . . <br /> 0 Ra-roof ❑Fire Damege Fax: 952�71-0882 <br /> Owrall Pro eae Deseri tbn: 1A l�� W ;� �� • <br /> Esti�nat�d Con�tructlon Valuation of cct exaludin lu�d � � ` � a <br /> rJ. <br /> APPI.JCANT ACKNOWLEDGEMENT: <br /> • AOrees to provide all Ulbrmatbn requked or raqueslod by the Buildinp Department; <br /> • CeRHisa thet Ihe informetlon suppfed ia true end corree.t to the best of hfe/har knowAeQpe. 't'ho app�caM raeajnb�as that thsy <br /> are solely respanelbk ipr eubrYlqn�a complete applic��tion belr�8 aware lhot upon faRure ro do so, the st�ff has�o akemetive <br /> but to reJeq i1 uNil it is complete; <br /> • Sorne or aU o!1Me iniormsticn that you are aeked to provide on this apptiC�tion i9 dasoNied Dy Slste 18w az sither(XIVBte Or <br /> oonbdenflal. PMvete tlat� Is ir�fonftaRiori which genera�ly�„�ba given to ths public but can bo gIVM �0 111E sUbJL�Q/� <br /> data. Confidenliel da� Is Inbnrtnatlon which generelly cannot be piven to ailhe�the public or�e subjsct at Me cleta. Our <br /> purpote e�nd Irllended us�of this inforRlafbn ie t0 annually updale our raeprds and raoorda of other pp��mmernal �genci� <br /> wrod �a�n+• If u reiuee to s �e IMormatlon thf e ' iom m �ot be issiagd. <br /> ►pplicant's Signature: �y <br /> Dete: �` / <br /> sa uoa�ed: cs-a�-2oos <br /> Z'd 06I9�L9TS9 3�IA213S .LIW213d Q 9 S I� Lb=6 T i0Z 6T �aQ <br />