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I S" / �/ � <br /> ll/L/ <br /> City of Orono <br /> Building Permit Applicatlon for Internal Work <br /> (windows, doors, sidi , re-roof, etc.) <br /> �� Permit number: r�0��-��.�.5 <br /> O�O�O CrysW Bay,MN 55323-0086 DaLe roceived: J���l��� � <br /> SCr�eetAddnss: R��by� —T'�'� � <br /> � � 2750 KeNsy ParkvreY Plen rovisw fee: ' <br /> Orono,MN 5�356 ,�`���02� <br /> Total Fee: ' <br /> ��; gr�_24g{gpp Fa�c 952-249-4616 www.ci.orono.mn.us i <br /> This appOcatlo�torm must bs complstsd in fuM and aU requfred inbrmatfo�must be submit�ed. <br /> Incompl�b appliatlons will b�roturn�d. (Pleese print) <br /> GENERAL INFORMATION: ' , -� ,_ � _ <br /> Job Sta Addnss: � �'�- (�;�./ ; ` <br /> WIII thb b�s Parad�of HarMs.R«nod�N�s Shoviress�Honw or oth�r Dbphy Hom�? Y�s No <br /> N y.s.e aW.�dd.,�.nc v�+���b��+��«+���r��+pr�r��a�ro a�s sNnc snufw a,s s.rvlcs wia ne <br /> rep�N�d unN�ss�pp/�nx d�no�n�babs tt�llkNrK on.tMs pnklr►p fa avsNebls. Non-p�+►r�ktsd ewnts wi not bs eMoweC. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: /t1;��/l S�'- oOf-, S�� 1.�►3�0(,.� LnC <br /> state l.ioense# p O/p a 7 7 Expi�ation Date: p 3/3� a O�a. <br /> l.e�d CertNicstbn Number: Expiretion Date: <br /> (l�or w�orlc on hon�s tlat w�rs cvnstruo�plor 1�1l7d <br /> ��: �b 3-�a �-9�q� c�� 76 3 0�80- 13 � c��q <br /> Maiiin9 Address: 5' �.�- c`f� c�tr• A'� v� ziP: 3 6 q <br /> Cor�ct Peraon: /�n,y Ir'jndlS4� APP�nt is: / Homeowner �c�a.o�.i <br /> Email andlor Fax: ')63 — y �7� QDO� -- <br /> PROPERTY OWNER W��RMATION' f z`"�^ <br /> Name: _.)�-, �C �t�✓ ' <br /> Phone(day): <br /> a�r�: _ �q l ����� Q� city: ��y 4�,�e ziP: <br /> EmaH and/or Fax <br /> PROJECT INFORMATION: <br /> Typ�at Pro� My�srth mov�nt m�y n4uin <br /> ❑D���) ❑R�wdsl ❑yy��amape I MCWD r+wNw 3 pMnits: <br /> Minnehaha Creslc Wa�ershsd DisMct(MCWD) <br /> � ❑Window(s) ❑Repair ❑Stortn Damage % 18202 MM1�e�onke BNd <br /> � ❑Siding ❑RssLoratb^ ❑Ofher.(aped�Y) � ��^�MN 55391 <br /> V , Phone: 952-471-0590 <br /> (' 'Re-roof ❑Firo Dsmeps � Fax: 952-471-0682 <br /> www.m i n nehaha c ree k.orq <br /> i <br /> ONlf'SQ PrO��NCf��Ofi: <br /> Estlmat�d Constructbn Valuaeton ot Pro�cc lucdudlnp land) i f �0� _ - <br /> APPLICANT ACKNOYYLED�iEMENT: <br /> i ,qpr,es�o provws aN Inl�onnttlo�nquk�d a roq�abd bY ths suUdirq�eperansnc: <br /> '� � CertlBes that ths ir�onnation wPPfbd is Uue and correct to the best of hislt�er knowledye• The aPP�M�o9nizss that they <br /> aro solNy rs�ponsibN for wbmittln�a�mpls�s aPD��^bsing aware that upon fdluro to do so, u,s sm�nas r,o a�ter�an�re � <br /> � but to rojec:t ft uMN it is car��ls�e; <br /> Some or aN d fhe iniartratlon lhtt y�ou aro adted L� provide on this applicatbn is dassHisd by Stete law as efthar private or <br /> ' ooMidentid. Privats dati is inbrtntfbn which fler�aMY cannot be given to the public but can be given t� the subjecx of the <br /> � dets. Co�Adentld d�ta Is kdOni�tlOn Whk�h �neraMY Cannot be giren Uo eilf�the publfc or the sub�ct of the data. Our <br /> I purpose and inbsnded we o(this iMortn�tion ie �o enn�Y uPdaos our reconls and recads of other govemmental agencies <br /> � reQuired bY ItW I(YOu nWsA tiD stKK�Y Cte in�Orrt»tlOn fhe aPP��'►aY nOt be issued. <br /> A►PPlicant's Signature: Date: _,�"�.1�y� � <br /> �sc uvaa�sa: os-o�-zo» <br />