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. City of Orono <br /> � , Bu�lding Permit Application for Internal Work <br /> ' (wlndows, doors� sidin , re-roof, etc.) <br /> �. Me!ling Address: Permit number� --b 0 � <br /> O�D�O PO Box 66 <br /> Crystal Bay,MN 55323-0088 Date reoeived: �. <br /> � � � Sb�etAard�as: t�eoslved by: <br /> 2760 KeUsy Parkway Plan roview fee: <br /> Orono, MN 56356 <br /> Total Fee: ��(P(P,�� <br /> Matn: 952�49-d60� Fax: 952 2a9-4616 ��Gl,orono.mn.us <br /> This appllcatlon Tomi must be completed In full and�II required►nfo�matlon must be submittad. <br /> Incompleta Appllcations wlll be returnsd. (P/ease print) <br /> GENERAL INFORMATION: <br /> �oa site nddres�: l� 1��`";�9� ��'� ,��, <br /> WIII thi�be a P��cN ot Honws�R�modelers Showcace Hams o�oth�Olaplay Home? Yes No <br /> N y�s,a spodal a►ro�nt pem�lf la roqW�ed wlfh PdICe 06,�erbnent end Gty Coundl approval BO d6ya pnbr to the ev�r►r. ShutNe eus 8erv�ce well be <br /> �sGulred uMees�pplfCent demor►sb+ete,s sullid��orr.�Jfe pa►lang ls avalle�ble. Non-pemHded evwfts w(Y nar be eNowed. <br /> CONTRACTOR/APPLICANT INFOR�IIATION: <br /> Name: II�J�!�w15�- �2om f,� S��/� d.��do(,.Q L:n c <br /> State License# ;Z 0 D1 D a 7 7 Expiretion pate: p3/3/��D�a <br /> Lead CeRiflce6on Number: Expiration pate: <br /> Phofw Nwr�on homss�t��scrucp�9�m 1978 �offloe) �6 �"a�8�� ��' � (cell) <br /> 9G � <br /> Mailing Address: (p 51 r-�,qr� G�- City: Q�1'e �p vL- ZIP: S 3 6 q <br /> Coniact Person: M1 G•� Applicant is: n r / Homeowner �circi.o�.� <br /> Email andlor Fax: ')63 .- y �7- QQO� <br /> PROPERTY OWNER INFORMATIQ.�I: <br /> Name: L�'L.� �''�� �i'��'-, <br /> Phone(day): /� <br /> Address: ����� -ljtj� ��`�'�' �'✓ City: L-�:�!a�.-dr��' ZIP: <br /> Email and/or Fax J <br /> PROJECT INFORMATION: <br /> Typs of Pro)ect: Any aarth movemsnt may requlrt <br /> ❑Door(a) ❑ Rsmodel ❑Water Damepe , MCWO revlew�p.rmlls: <br /> Minnehaha Creek Wa/ershed DIBWcI(MCWD) <br /> ❑Windaw(s) ❑ Repair ❑Stom►Dama9e 18202 Mlnnetonke Btvd <br /> ❑Siding ❑Restoretlon ❑Other:(sPedly) P one: 852�471-0590 <br /> �R�roof �Flre Qame� �minneh�hac�ek.orci <br /> .....,_� <br /> Overall Pro ect Dssc�i n: <br /> Estlmated Constructlon Valuation of Project(exeludlny land) i ��� `'�'" <br /> APPLICANT ACKNOWLED�3EMENT: <br /> Aflrees bo pruvide all intonna�on required or requested Dy the 9uilding pepartmertt; �� <br /> � <br /> Ce►tifies Ihst the intom�ation supDGed is true and CorreC!tv fhe best of his/her knowiedge. The�pplfcgM recognizes tt►at they � <br /> aro sobly rosponslble fur submilting e complete applicaUon being eware thet upon fellure to do so, the sta(�has no altamaUve � <br /> but to re)ect it ur�tll it is oomplete; � <br /> Some or all of Mo IMormadon that you are aoked to proWde on Utis application is classified by Soate lew es elther private or � <br /> confidenUal. Privafle date is infom�ation whlch generelly cennot be given to the pubUc but can be given to the subject of the <br /> de�. Confldentiaal deta is Informatfon which yenerally cannot be glven to eftt►er the publl� ar the subject of the dete. Our <br /> purpose and intended use of thls inTpcmBtlon is ta e�nuelly updste our reoor�ds end rocorde of other govemmental agencies , <br /> ulred b law. If retuse to au iMormetbn the a ' tron ma not be issued. � <br /> ,��C � <br /> APplicaM's SlgnaWre: � Date; �.���� .` <br /> ��uoe�e: o�.o�,zo�i <br />