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Aua-12-2009 09:31am From-CITY OF ORONO +9522494616 T-T19 P.002/002 F-A04 <br /> ,,.,o. � �• _.., _ ,.. ... <br /> ' r City of Orono <br /> Building Permit Applicafi�on for Internal Work <br /> (windows, doors, siding, re-rocf, etc. <br /> ��'�'��� �Permd n�rnber D <br /> 0.�,O,�,O Po Box se . a <br /> Cry9t91 gay,MIV 55323-0086 Dete received: v / 0 <br /> a Sbeef Addnis� Received 6y: <br /> 2750!(,elley Parlcway Plan T�eView fee� <br /> p�� Orono,MN 55356 � <br /> Maln� 952-249-4800 Fex: R52-249�616 www.a.orono.mn.us �Total Fee:' ��'1��� �9 <br /> This applicatlon form must be c�mpleted in fuu and all req�ired information must bH submitted. �,,Qp <br /> Inwmplete applioadons w10 be retumed, (P/ease pnnq � • � <br /> GEN��INFORNu►noN:�b�Q �� � / � a��� <br /> Job Sibe Addwss: �� � � <br /> wll this be a Parade of Homes, Remodelers Showqse Mame or other Dlspl�y Home? Yes No <br /> Myea,e speciel ew�►t painrt is�apulnid wJEh Pohoe DepaM�anf end p7y Counci�app�ova160 doyt9 p�ar b Ohe event. Shudle Dus senice wIp be <br /> /equU�d unlass appNCaAr demor�ebstes sulndenf on-�7te p9dvl+g Ls av1!/i41s. Ab/l�pe�m�teC eve�Ifs wUl net de adowed <br /> CONTRAGTOR I APp�;I�ANT 1 OfZIIAA 0�1 N: , � <br /> Name: 7 �'�' r�5• (�r..hP.r � <br /> Stste wcense# 3 � E�Ira6on bate: ( 1 a <br /> Phone: � - '1 � !�0 office cel <br /> Malling Addre.ss: 't� Y C' :. �� Zlp: .� <br /> Cont�t Person: i Applicant is: Nomeowner �cMp.o,,.� <br /> Flnall snd/or Fax. o'��d�1 r b <br /> PROPeRTY OWNER FORMATIO - <br /> NaMe: a` Pr G.S�e <br /> Phone(dey): — D- D /� <br /> Address: 0 D Ci _ LJ�/10 21P: �5,��0 <br /> Email and/or Fax <br /> PRo.�ecT INFORManON: <br /> Type of Pro�eoL Arqr earth mav�t may require <br /> MCWQ�vletil�3 permits <br /> O Door(s) O'Remode�. D Water oama9e . . <br /> Minnehahs C►selc Wate�shed Disdict(MCIND) <br /> �Vlfindow(S) (�Repai� ; ❑Sbrm pamage 182b2 Mir►netonka�Ivd <br /> DeephavEn,MN 55391 <br /> ❑Siding ❑Rest�radon ❑Oth�r.(specify) Phone: 652-471-0590 <br /> " Fa�c: 952-471-0882 <br /> 0 Re-roof ❑Fro D mage www.minr�ehaheaeekora <br /> Overall Pro ect Descr( o�: ( �,C4rn er� l� G'� �r�,�' a • ^ , <br /> Esdm�bed Construetion Valuation of ProJect(exclualnp land) S .3�$'�a']� <br /> APPLICANT ACiUIOWLEDG�NlENT: <br /> • Agrees to provide all InfoRnaqon required or requesred br the Buflding Depal�tme� <br /> • Certlfies that the Infortnadon supplied Is trve and oome�t Uo the best of his/her knowledge, 7he epplksM reCognites that they <br /> are a�ly�sponsible for tubmitting a complete epplication being avra►e thst upon failure to.do sn,the sta(f has no aliemaGve <br /> but to ro�ect it untii it is amnplats; <br /> • Some or all cf tAe I�formation that you ere ssked to provlde on this eppliGatio� is da9sifiad by�;�te law as afthar private or <br /> oonfidential. P�lvate dab is lnfom�atlon whidt penereAy cartnot be givon to the publlc but can ba given to the subject of the <br /> data. Confidential data is infotmetion which genarsNy cannot be given to elther the publl� or bie subjed of 1he dat�. Our <br /> purpose and intei�ded use o(this infolmation is to annuaJly update cur reaordo E�f►d recflrds of�ther goverrWne�tal apenrJes <br /> ulred D IdW. If u feNse to su into 'on the a licatfon rna not be issued. <br /> Applic,�nt's Signeture: Date: ��l�9 <br /> �ast u�aaien: os�oa.2ooe <br /> �en tw �n.�• / n/1/1� ... � ' <br />