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� C�-� ��ss <br /> ; � '� City of Orono <br /> Building Permit Application for Internal Work <br /> windows, doors, sidin , re-roof, etc.) <br /> �O� ���� �cnur„bsr: o2U��-OI,��S�i <br /> O O ��•r,�,ss�s-ooes ���: .3"//8' // � <br /> RscMred by: <br /> � � Sbwt Addross: —� <br /> 2750 K�Ney ParkvvaY Plen review fee: <br /> � Oe�o��o.MN 55356 <br /> �___ Total Fee: <br /> �: g�_248�pp Fa�c 952-249-4616 www.ci.orono.mn.us ��b�O�`� i <br /> This appYcatbn form must bs compisted in f�and aN required iMormation must be submitted. <br /> In�ornpl�b spplicstlons wlll b�rotum�d. (Ple�ese prir►t) <br /> GENERAL INFORMATION: '� . <br /> Job Sib Addnas: ��� � �_5 C.�����(��� �'��` <br /> WUI this b�a Pa�e o� ShoMress�HonM or oth�r Diapl�y Honw? Y�s � No <br /> N r.s.,ap.clN.w+r v«►rrr fs�puY�d w�N Pn�o.D�p�rbn«+t�nd CMy Co�r�dl+ivv+�'r��a�uo chs.wnL snufus aua ss►v�cs wla be <br /> �squNsd urll�ts app�/crk drmon�bal�s a�lONairnt w�-�N�s pn�inp it av+�Nabis. Na►�miiNrd swrMa wi�not bs allow�ed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: /1'I,�WIb*- 00 � 5��� i�.rhdo�.d Ln� <br /> State License# DO/4 a 7 7 Expiratio� Date: p3/3� ��t a. <br /> Lead Certificatbn Number Expiration Date: <br /> (far warc on/arn�s tMt w�n eonstrucl�prb►b 1� <br /> ��: �b 3-�a �-q�q 6 c�� 76 3 a8o- I 3 � c���� <br /> Maiun9 nddress: S ,-�.�r c`t� c�y: A'-� v� Z1P: 3 6 Q <br /> Contact Per'son: �pnn,y �GS4h_ APP�nt is: / Homeowner �c�a.a»► <br /> Email andlor Fax: ')63 -- y �7— QDD� <br /> PROPERTY OYYNER t" -� <br /> Name: ��G' `:.'�t `.� " �✓� <br /> Phone(day): ` � , <br /> Address: _ "��- , .� Q.�G%��� �. �Y� _ ZIP: <br /> Email andlor Fax <br /> PRWECT INFORMATION: <br /> Typ�at Proj� My�srth mowm�M rrNy r+�4uln <br /> ❑D�i$) ❑R�rt�odsl ❑1Na�sr�emape I MCWD rwNw 8 pKmib: ' <br /> i Minnehahe Cr+eek Wa�srshed DiSMct(MCWD) <br /> ❑Window(s) ❑Repai� ❑SUom��rt�e�e j 18Z02 NNnne�aNca BNd <br /> peephavsn.MN 55391 <br /> p sb�� ❑�� ❑o�(sa�r) Pno�e: �2���-osso <br /> (�Re-toof ❑Ffro Dams�e '� Fax: 952-471-0682 <br /> www.mi n nehahacreek.orq <br /> OvKall Proj�ct D�sc�iPtb�� <br /> Estirtiabd Construetlon Vsluatlon af Proj�ct l�xdudin�land) i f �c.9�o - <br /> APPUCANT ACKNOWLED�3EMENT: <br /> qgross bo provld�aN h�Morrr�tio�nquind or roQuss�sd bY ths Bu�din�Departrnsnt: <br /> � Certi(bs that Ihs irdo�nwtbn suPP�� is true�d oorrocx to the best d his/her Iv�owledpe. The aPPlicaM recog�izes that they ' <br /> � are sowly rosponsibl�for submlttkW a�mpl�s aPP����9 awere that upon failuro to do so.the sfali has no altemative ; <br /> � but tc rojsd it untll it is aort�ia�e; <br /> � Soms or aN d the ir�ortn�tlon fhet Y�ou aro aaced Lo provide on this applicafbn is dassitisd by State law as eHhar prnate or , <br /> � co�iidential. PrivaLe d� is krbrt�fbn vrhk� psneraNy cannot be yNen �o the public but can be piven to the subjecx of the <br /> idets. CoMideMfa� dtla Is kdOmlatlon whbh ya��aMY Cannot be given �o eilt�r the pubNc or the wbjeCt of the deta. Our ' <br /> � purpose and inosnded we of this IntOrtn�tlon is LD annuaMY updem our r+econds arW r�eco�ds of other govemme�tal agenaes <br /> reQuired bY hw N YOu frG1N OD thA in�rtr�tl0� the aDPMcation meY nOt bs issued. <br /> Date: ' S', �'��� <br /> ApplicanYs Signature: — <br /> �sc uvaa:ed: o�-0�-20�� <br />