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Fab-21-2012 09:18am from-CITY OF ORONO +8522494616 T-443 P 002/002 F-1B1 <br /> • ' v��� v� v�v��V . _ <br /> . Building Permit Application for Internai Work -� <br /> � (windows, doors, sidin , ra-roof, etc. � <br /> -• MaH1n8 Addrees: <br /> . '��� PO Box 96 Permet number. � .. <br /> Q Q Crysiel9ay,MN 65323-0088 Dube rooefved: ��/ /Y... <br /> � � street Address: Reaiv�rd by: <br /> � 2750 Keqey Psrkuvey Plan r�uiew fee: <br /> a� Orono. MN 55356 <br /> ,. . - rQ�i F�: /s�, 5�.3 <br /> Mein: 652-249-4800 Fax: 9b2-246-4616 ww�y.cl.orono mn,�s <br /> This epplicaEon foRn must be compleDad in full and all requir+ed informatian muat be Submlt�ad. � <br /> I�comple� applicetlons will be returneid. (P/essa prini) <br /> GENERA� INFORMATION: ��� C � ,�� �d <br /> ,�ob si�aaaress: <br /> Witl this be a Parade of Homes, Remodelers Showcros� Home cr other Oisplay Harn�? Yes No <br /> If yos,a speeial ev�e�rt psntrlt is►aqWisa wtt�AoHc�e peperLnent ano Cl�Coundl epprov�/60�rsya pilor f��he swnf. Shuftb Dw eeMo�Wll/be <br /> requl,�d unbsa eppticanf demonaharos suRPc�nr on,slle pantc�np�a s+reueble. Non-psrmilesd eyents,�i//not pe albn,b <br /> CpNtRACTOR/APPLICANT INFORMATION: <br /> Name: Kenewal �iy Andersen <br /> State License!t � 1920 County Rdad "C"West Expiretion �ate: <br /> Ptwne: Roseville,MN 55113 (ce11) <br /> Mailing Address: License#BC130983 ��L-�- Z�p: <br /> Contact P�r6on: ___,___ 65I-264-477� �t is: Coniractor / Homeowner �c�tii.ane� <br /> Email and/or Fax: <br /> _ . _._ ._ _ ._ � . . -- -- , - � <br /> PROPERTY OWNER INFQRM T N: � ' ' "` <br /> Neme: C.,\' S l�iQ.1f15Cri <br /> Phone(day): 5 , <br /> Address: �► City ZIP: - <br /> Email and/or Fax w • <br /> PROJECT INFORMATI�N: � � � -, a ; � � <br /> .ry�e oI Pro�ct: . <br /> Any w ni►o ment m�pr u�ro <br /> __- - . - - MCWq�view 8 pacmlls._ <br /> ❑Door(e) ❑Remodel ❑Wecer oemage .._ , <br /> ❑�Window(sj �...." p rtepafr � Mirmehaha182D2 Mlnneto�ka B�Ivdlct(MCWD) <br /> Q 5torm Dam <br /> ❑Siding ❑ Restorat�on ', ❑pp�r $ @ - p�ePhave►1,MN 55391 <br /> -- , ._ .. _,. ._ . _ . .. _ ( P �Y) .. _ Phone::R92-47,1-0594._• _. . _ <br /> []Re-reof []Fire Demage Fex: 962�471-0682 <br /> 1 <br /> Ove�all Pro O�crl tion; <br /> EBtinlated CoriatruCtlon Valuation ot Pro ect(excludin la�d $ � <br /> APPUCANT ACKNOWLEDGEMENT: � <br /> - Agrees to provide all Info�rneflon required or requesled by 1he B�ild�ng peparbnenk <br /> • Ce�tifiee thal the ir►formation 8upplied is true and oor►ect to the best of hi�/her knowledge. 7he epplicant tecoynlzes that they <br /> ere$olety responsible for su0mitling e complete applkstion beine awete that upon fallure to do so, the stafi hes no aRematiue <br /> but to reJect It until It is oomplete; <br /> � Some or all of ttte infotmetion that you are ssked to pivvide on this applioatlon ia daoslfied by Stete 10w ee aither prfvete o� <br /> tonfidential. Prlvete date 18 informstlon whidt generelfy cannot be gNen to the public but can be plven Op th� eub�Ct of fhe <br /> dela. Cpllfldentia{ defs is Informetien which generally cennot be given Eq eRher the publlc or the sub)ed of tha d�. Our <br /> purpoae a�d Into�ded uae of ihis Infom,eticn �s to annualry update our recoroa and raeoros of other gover�menrai a�ene;ea <br /> uirod lew, It ou Bfuse to su the Intormeilen Ihe a 1Caflon me no1 be isaue�f. <br /> Appl��ant's Signature: ��'� Date: _���C�/J�� <br /> �a�upda�ed: o�-o�-2coe <br /> Z •d p619bL9T99 3�IA2l3S llWa3d Q '8 S �1 �O =Si ZTOz Lj qa� <br />