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Jan-04-2012 01�13pm From-CITY OF ORONO +9522484616 T-366 P 002/002 F-028 <br /> ,,�,., v���t v� v�v��v <br /> , . � Building P�rmit Application far Int�rnal Work --, <br /> � (windows, doors, siding, re-roof. etc, , <br /> Malung addreas: Permit number: <br /> „ ��� Pd eox 68 — <br /> . <br /> , � � Q Cryetel Bey, MN 66923-OQ6B Date roceive� � - � <br /> � � ' Sfreef Add�as; Recaived by: <br /> � 275D Kelley Parkwey Ptan revlew fee: <br /> '� o� Orono, MN SS356 <br /> � ,� T«�F�. � �q �9 <br /> Main� 852-249-4600 Fax: 952-24�4618 www.ci.orono.mn.us <br /> ' this applicatfon form must be completed in fu11 and alt required infarmation rnuat be subrnitted. <br /> ; � ,, „ Incomplete applicationa wIN be�eturned. (Please pnnt� <br /> G�NERAL INFORMATION: <br /> ,Job;Sfto Addres�: �5 ���(r�,p��� 11 . �• <br /> .Will this be a PersOe of Homea, Remodelers Showcase Home or othe�Diaplay Hc�me� Yes No <br /> .,, Il y9s,e ype6lal ewnf p�rmlf l��eOWtid wllA PoNCe deperrin�nf ond Clry Counell Apprpvp!BO q�yd Wbi to the e�enL 3hu�btN Selvlpr WI/I DO <br /> requ4�d unMss eppJkant tbmOnatrefes suNicrent on-sitg parMqp Is su+e�eb/e. NoA-permllled oNants w!M mtde olbwed. <br /> ;�.ONTRACTOit/APPI.ICANT INFORMATION: <br /> ,;Narne: Kenewat �sy AnQersen <br /> =-S'tate Ucenae# 19Z0 CounLy Road "C"West Expiraticn D�te: � <br /> .Phone: Rnsevslle, MN 55113 (�e��) <br /> � Melling Address� LiCense #BC130983 Cft�.-�y. ZIP: <br /> Contact Person: 651•264-4777 �►is: Cantracb�r / Homeawner �c���ec�e� <br /> �mail and/or Fax; <br /> PROPERTY OWNER INFORI�I�710N: <br /> Name: Ed t <br /> Phone (day): � 5 <br /> Addr+e8s: C � ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> T�rpe of Projeat: Any sarth rnovement m�y requlre <br /> MC WO_rrviow b psrmlta <br /> (�Doot(s) ❑ RemodN ❑Water Oamege ' <br /> Minnehaha Creek Weterehad Disfrict(MCWD) <br /> '�VN11�few($� " ❑ R6peir ❑ Storm Damage 18202 Minnetonka Blvd <br /> []Sltll Deepheven,MN 65301 <br /> n9 I ❑ Restoratlon []Other: (apecifjr) Phone: 932�471-05�0 ,. <br /> ❑Re-roof ❑ Fire Damage ��eX: A62�471-b8B2 <br /> Overall ProJeCt D9scription:'r�,�lc►�[n 5 .;,n.�n�.,a. � 1?��.}�a �r�f W�,h •Q1X�S�no, <br /> Estlma�d Conatruetion Valuatton of Proleet(mxeludlnp land) i 1314�� �b _ ���, <br /> � <br /> � APPUCANT ACKNOWLEDdEMENT: � <br /> • Agrees to provlde ell Infarmatlo�requlred or reque�ted by the Bu►Iding Depsrtment; <br /> . CeRi�es that the informetion eupplled iB true and oorrect to the best of hle/he�knowledsa, Yhe applfcant�eoognfzes fhet ther <br /> are solNy respor�sible for aubmitting e Cpmpleto appllcation being aware tt�gt upon 18ilure Yo do gp,the etaif Mes no�Itemetl�e <br /> but to re�ec! it until it Is oomplete; <br /> • 8ome ar ell of the informetlan thet you are asked to provide on this abplication Is cl8sslfied by Stal�law ea either pr"Naie ot <br /> oornldentlal. Prfvate data is intormation which ggnerelly Cennot he glven to the publlc but can be given to Ihe subjed a1 the <br /> data. ConAdendal date ia infamadOn Wh'rch 9enetelfy cennot be gNen to eltll�r fhe publ{c or the Bubjed of thi daf�e. Our <br /> puryose and intended u9e ot ihis informefion la Lo annually upOgte our recor0a and �eaords oi ofher EJovernmen181 eger1c188 <br /> required by lew. (f�rou refuse to euppiy the IniormeUpn the eppliceiio�may net be Issued <br /> ApplicanYs Signature� _ Date: y � � � a <br /> Laat Upasted: OS-04-2008 <br /> Z •d D6T9til.9ZS9 3�If+a3S lIWa3d Q '� S � Lt =2t 2TDZ b0 UeC <br />