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, � City of Orono <br /> Bullding Pernnit Application for tnternal Worlc <br /> (windows� doors, sidi , n-�oo�f� etc.) <br /> A�ha Ada�rera: P�it nun,Der: o�f��/— C�03 <br /> 0�OsrQ Crystal BaY�IiM 55323-0066 Date neoeivsd_ J"� / � <br /> � � ��P��y Reoeived by_ ....�1 <br /> 276D Plen review fee: <br /> bono.NW SS9.S6 <br /> To�el Foe: <br /> Meln: 952,2�4�1800 P�c 932-249-�616 www.ci.orono.mn.us <br /> 11�ls appNcatlo�fbmi must b�compi�ed In fu1�nd ad requbsd intorrr�ati�or►must be submicted. <br /> �p��PP�iaatlons wNl b�nturn�d. (PYaeBe prtr►t) <br /> GENERAL INFORYATION: c /� <br /> Job Sid Adclr�ss: ,J� ��dls��b�.� f/'/`rr <br /> Wlil tfils b�a PwncM o�Harrs, 8how�as�Ho�e�o�ot1t��Dbphy Han�� Y�s '-�No�_.'- <br /> �s�.a;P•dd.wr o«n�r�nq�ira.�N Pbio.ap.rn�wr«id ay car�or.Ra�M Qo aya Orior m d».r.nt s�er.aua a�vios wdl oe <br /> �Vu4e0 unls3s qpplo�rt�mor�s adlld�nt o►►-�s p�/khp t�a�tlAb�s. /Mon�+n�Rdsd A+�w�t w�not bs aMo»�se. <br /> CONTRACTOR/APPLJCANT IIii�01�11ATIpN: �/ <br /> Name: IfJ�d GJ�S� O � SG i I.A�Gl� Ln� <br /> s���� 2 vav o a �7 ��aor, �: _Qai 3� a o�.� <br /> Lead Certiflc8tlon Number. F..�iration D�De: -- <br /> (1br wve#an Aonws dnt�� 1�1�7A _"" <br /> �,o�� �6 —k� �- � c�� �6 3 a8o— �3 � c��n <br /> MeiUng Address: r-►.air- G`I- C[ti: vG ZIP: 3 6 4 <br /> Co�act PeBon: n, 4n AppiicaM ia: / Homeowner �cra.o►�.�,-.. <br /> Emall and/or Fax: _ � 63 - �/ ?�- 00 <br /> PRCPERTY OWNER 1"� TION• , <br /> Name: , C✓c�.n,� L.vf`� <br /> Phone(day): � <br /> , / <br /> Address: _ 5�, , t'1L` Q;��� City: -��:�l-����- ZIP: <br /> Email andlor Fax <br /> PROJECT INFORMA110N: <br /> TYp��'1 R�� ! My NAA n�ewnMnt mq n�quln <br /> i ❑Daorla) ❑R�nwdsl Q W�sr Damepe MCWD e�rvNw�pKmlls: <br /> � Mlnnef�Ne Creek WsO�+ed Dl�trict(MCYVD) <br /> i ❑Window(s) ❑R�epel� ❑SEorm Datnege � 18Z02 Mlnne�onka 81vd <br /> � ❑Slding ❑Ra�or�tlon ❑Ott�er.(sped�Y) ' ��,MN 5639� <br /> IPhone: 962�71-0590 f <br /> �Re-roof ❑Flre DeA'feps � Fe�c 952�471-0862 <br /> I w�r+n.mmnehahacr,�k.ors� <br /> owrau pro�ct o..�iptlon: <br /> Esturubd Constivctlon Valwtlon o�f P��Ct(�coludin�I�nd) s � �'�'� _„.T� <br /> APPLICANT ACKNOWL.�D�i�YENT: <br /> � a�w4 m prw�ds.N f�rtnNior�rnq�.d or requssesd by ms BuOdinp�epertmenr <br /> � <br /> � Certlfi�d�at C�e In�pnrotion <br /> euppNed I�true aM tmtreCl DG Ib besc of hiBIF►et lonowf9dpe. The sppYc,ant recopnl�ms tnel tney � <br /> � are soWy ntpa�sbl�f�wbmittln0 a oompie�aRP���9 owaro that upon tailu►�to do to, !hs atslf hse no altemative ; <br /> � nut w rejed n w�lll n is c«nple�s; , <br /> � Sorne or sq ot 4w irtfonnetlor� thtt you are aslo�C L�provi�ds on ihis epplk�tlon Is dstsflfed by SCsto lew as olt�er prtvaLe or : <br /> ; aorsliOentW. F�rivab dad h irdortn�tlion wld�per�eraly cennot bo given to the p�lic but nn he 9iven to the subjed of t�e ; <br /> � deta. connd«�la� ds� 4 infam�llon wh�h �snerdly caruac bs glven tti eltlwr the p�Nc or u,e sut�cc ot a,e dara. our <br /> i purpoae�nd b�Osrid�d u�s of thb Irrbrt�nfbn f� oo annually upds�e our recads and reoonds of otl�er go�emmental agenc�es � <br /> reCuirod b�►lew. If 7R�u re�iras 10�ur�Dly ths infortnv110e�fhs sooYosliOn m9Y not b�Iesued. y <br /> APPIIcanCs Signature: f�"`� Dat.: �t�"'/�•'(� <br /> �,u�ea: o�o�,zot� <br />