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MAY-24-2011 13:16 F�om:GORDON JAMES <br /> ; <br /> s I <br /> Ci <br /> ty of Orono I <br /> � Building Permit Application for Internal WQrk I <br /> windows, doors� siding, re-roof, etc. <br /> ��y,r.'��'--�-;.�s.\ i MoNinq Addross: .. <br /> �u BoX ss Perntit'numGar: D �D(�3 <br /> �O �p I c,�►s�i aay,MN 55323-006ti ot,ue rooe�vea: <br /> ' �� , " a Street Addresa: Recelved by: <br /> \�'Q'� p� I 2150 KeYsy Parkway Plan revi�w fde: <br /> ..k � I Orono,MN 5535Fi .. .._. <br /> ,...s-..�.. ,� / � /. 3� <br /> Main: 9 Z-249�600 Fax: a52-249-4816 1 otal Fee: <br /> u!�W.Ci.orono.mn.us <br /> -�,rr.-;. <br /> This a pllca�ion form rnust be cptnp�eted in fult snd all�quireci information must be submitte . <br /> Incomplolc applieatio�a wlll be neturrn;tl. (p��ese printJ <br /> GENERAL INFORM 710N: � <br /> � Jcb Site Addrass: S � I O� <br /> Will this be a Parad of Nomes, Rernodalers S owcasa Hom r other Display H a7 es �� No ` <br /> It yy5,tl sper,iBl evenf m�K!a�q�d wlUt paica�w�nrf�t end G'y Councll ippruva/8p deys Pilor lo the event. Shutf/e bua ervir:R w�T/hr <br /> revulrvd au ap�k;a,H o�rnonsar��s suA7c►anf prr-eqeµ,rkiny i��lle6le. Non-pom�iped events wdl not 6ra n�owe��, <br /> CANTRAG70R!AP�+�ICANT IN�O MATION: <br /> Name: o�c�Oh �..py� ��1 ✓1 <br /> 5tate License# Expiratipn O�te: '- <br /> LC�d CeRlflcetion N�� bar: �.. �� Expiraifo►t Dete: V ^ <br /> (lor work on homes�f wtn wnsD'�u�tec/p�(a[018fd �� <br /> Phone: 3 • t{'�1. �31'1�,._. (otfic�) <br /> Mailing qddress: ���' g� ��Z� (cell) <br /> Contact Persor�: � 3 ._ . CitY ;1 ZIP: q ..... <br /> • � ..� ApplicAM i�: o tra r liwneowner �ckr oee)•1-- <br /> Email and/or FaY: � _ I <br /> PROPERTY OWNER�NFORMaTION: <br /> N�mo: � � .C1/�$ � 1'� t e�n,T <br /> Pfione(day): � -.. -- — _ <br /> Addres�. _ u.�. �''� S-i-� GitY��� ZIP: S '-�l� <br /> Email and/or Fax _�. ��rt . <br /> �b.r.�.._ �� .���. <br /> PROJECT INFORM TION: <br /> Type oi ProJect: �- �• - .. <br /> AnY earth movement may quire <br /> ❑ �n�r(s) CI Remodei ❑Waler OamapA MCWD neview 6 f�grm) : <br /> ❑Wlndow(s) ❑ Ropalr Minru�haha Creek WalerSh6d DIsVI t(MCWD) <br /> I]Stvrm t3amage 18202 Minne�anka Bl�d <br /> ❑Sidinp n RP�10�tlon ❑011►er.(specliy) Deephaven,MN 55391 <br /> RC-rool Phonc: 952�71-05JU <br /> LI ❑�irc Damaqe _ Fax: 852-471•0682 <br /> - . wVw. n h h�rinpk <br /> Ovcrall Pro ect Deseri lioe � ---- <br /> O i�' <br /> _E9tim�tod ConutruCtt �Valuation vf Projoct('excluding land�� s Q�— . " <br /> APPLICANT ACKNO EDGEMENT: <br /> ----- <br /> Agrees to pt��vi�le sll intom��llon —_ ......... <br /> required or requexst�i by Ihe Nuilding Depart�nenL;^� '--"1 <br /> � C:erb��es that the i ormation suppli6d is true and corr to Ihe be+st of hislher knowl�,lye;, 7rte applicant recog izes th�t thCy � <br /> arr splely respon ible for eubmtnin� ��mpletc ap tl�n being eware thrt upcm fPilure to do so, the Stelt has no allernatiVtl � <br /> hu�to rejec;l it unUl it is complete; , <br /> � S��mH or all ot Ih Infonn8lbn lhat you are� k9 provide oq Ihis ep�lic&Gan is classifisd hy St9te IAw a:, ei l er private or <br /> eonntlenlial, Pri te Oet6 I i ich erally cannvl �n yiver► la tl�e public but can bs gi�en to die ubjeG of the <br /> data. C:qn6dentia d infol'metio i n�rdlly annot be given�to elther tFw public or tha subJect ef q n�ita• Ou� <br /> purposp and mla d use of ehis i rtnat Is w an elly upclate our Fe�:u�ds and re�rds Of other govemme tel agAnciPs <br /> . re uired law f u rofi.�e lo s _ Ihe ormadn rh9 dD�ucation mav not be issued. <br /> Applicant's SignaturP. _ __.. , Date: 2� C� <br /> Las1 UpdaleA: Q;�Q�-Z011 <br /> � � <br />