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Aug 05 10 11:57a Pro Custom Builders 952-949-8692 p,1 <br /> Aua-05-ZOl 10:49am From-CITY OF OROIFO +952Z4846i6 T-390 �P.001IOD1 F-A48 <br /> � � City of, Qrono � <br /> Buil�ing Permit Applf�ca�ion for Interna� 1Nork <br /> (windows, do�rs,`siding, re-rd�o�, etc.) <br /> ��Q�+ MailJPO Box 86 , ' _ _ Pehnit nu3nbe�: �lb!�D�Z ) <br /> V V :�ysini o�ay,iviiv�3�3-vuov uale fBt6N6tl: 8 <br /> � Str�etAdd�ss: Received by: - . <br /> G� 2750 Kepay Pe�kway �Pian review fee: <br /> � $� Orono,MI�55356 _ � <br /> _a.�g1� Tot&I Fae: � .'f}2. � Q <br /> Main� �aas�qflnn Fax� q5�.9 w•w�i�M��m�••� � . .:� <br /> This application foorm must be campleted in full�nd all required information must be su�rtiibsd. <br /> Incompfats appiications wiI!be returned. (Pleasa pnnf) <br /> GEkERAL I�tFORMEATION: _. .� <br /> Jab Slte Add►ess: y D fL�c�� � ,n xa. /-F� , <br /> Wiil this be a Parede of Homes, Rerr�elers Showcase Home or other pisplay Home? Yes Mo <br /> I/y65�a spe�a/ev9M pertnit is raq�ired W�th PoBce Oep6nmen�end Gtity Cou/teil epprova!�0 days p�fo tRe ave►iL Shu�Ie bus seNlCe wi�l be <br /> �9QVfl�IJRIOSS BDP�C811t Q8//f0/iSbB�d BY�C/A/II O/I•{'.�(B OAIt!!!v�R 9Y8���!9. !4�^.n.r.srn;l�nre����'....:.a.. .r_Nv� � <br /> _ .�— ..v�w rv:wM. <br /> CONTRACTOR 1 APPL�ANT INFGRMATIO : ' <br /> Name: �,�o C v s `r n n� c► f/pr�.;S � � � . <br /> Siate�icense� �' � Expird�tian Oate: 3 � <br /> Phane: / o�Ce (ceU) <br /> Maiiing Addtess: ' C�t ��? �►,`�ZIP: tS"'�'z S/� <br /> �.:�ri'f•`_�st r�-���%�: d• 72•. f.rp��va�'it is. vGi�u'�Gtvi l iit�flieG'wfieF ;cnei.onel <br /> Email and/or Fax: - - <br /> PROPERTY OWNER iN�ORMA710N: ' . <br /> Name: O <br /> Phone (�ay): - �� <br /> Addcess: <br /> _. ��_ �p: �i / <br /> Email an�lor�ax <br /> PROJ£CT iNFORMATION: <br /> Type of ProjecG Any earth movement may requ�re <br /> MCWO review&permits <br /> ❑Door(s) �Ri+t7lOd9� G11M3Le!�EmIB� : <br /> ` ' ; ' Nlfinneheha Cree�k Watershed District(MCWO) I <br /> �WRdQ!"1;�) �R9�1� � Si'vrRl ^vafi8� i i ;' � 'I6Gt�2 MinttB1011fIa 8Nd <br /> , ; , ; , Deepf�avan�MN 55987 <br /> ❑Siding ❑Restora�ion ❑ ,Other. (sP�ci�r) ' ; ; Phone: 852�4T1-059a <br /> Fs;c: 952�i1-0682 <br /> �Re-roof Q Fir�Damage � ' ' ; v_mkw.rnin ehah_acreelc.ora <br /> Overal� Proj�ct Descriptian: � i <br /> ��;r�ia�i�.w�sf�ucii�in vaivation of Project(exciuding landy S 7.04� . O� <br /> APPI.ICANT ACKNOWLEpCEMENT: ' �— <br /> � • Ag�ees to provfde atl iMamation requj�ad or requested by Ihe Buildmg Depahment; <br /> ( • Certifies that tha informatlon aupplied is true end comeet to the best of hislhar knowfedge. The appiicent reca�nizes th�t theY <br /> ere�ioly rdsponsiate for sucmitong�complete applicatian being aware tbat upon fa�iure to do so,ihe statf has no afternatJve <br /> but ro rejeCt it until it is contplsta; <br /> • 5ome or all of tha informa�on that you are esked to provide on this app(iceaon is dassifisd oy State law as eithec private ar � <br /> Confidentiai. Private da�is i�ormation which oenerally a0nnot be given to the publle but can be gfven to the 6ubJect vf the <br /> I deie. Connder�i;a1 data is iniortne�on whlch gerte�ally cannot be gtvan to eidtet th� putilic ar the suk�ect of the date. Our <br /> purp�se and inte�tded use ot lhis infonnatian is to ennaaHy uodste aur recsor+�sds and re��d� of�rther�.�r�rs:znw:ag��;;,s� <br /> i required bv lew. If You refuse to supDly the inforrnatiq�,th�aaalicati f�mav not be iseued, <br /> � � <br /> Applicanf's Signature: Date: � �d � <br /> �• <br /> 6gat Lipp3SJ0: R?-!!�!•?{�"s ' ; <br /> . . . _ . . • � .. <br />