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FEB-13-2012�14:Q� From: To:+9522494616 P.2�3
<br /> . � � �y�'� o��` l
<br /> �i✓�"ZI��PI'j?�
<br /> City of Orano
<br /> � Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> �,m,�y�drl•�:�: .� a0/
<br /> '�f•���d�;, PO Box 66 Pcmnit nurnber. _
<br /> //O 0� Crystal Bey,MM 55323-0066 Date reoelved: _
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<br /> ���� Street Address: p�"�bY�
<br /> ��,P "~ �� 1/50 Kelley PancwaY Plan revisw 1e9; __.. _ -
<br /> �ivt,r� o�'.;,.� Orono.MN 55356 �� �/ . �lo
<br /> %`---'�'f 'fotsl Fea:
<br /> Main: 952-z4�pp FaK: 452-2�9-d616 www.ci.orono:mn.us
<br /> �7his applicauon form musl be wmpletad in iull s�d all r9quired informatbn must be submitted.
<br /> Incomplete appHcatlons will be�tumed. (Please print)
<br /> GENERAL INFORMATION: 1 �
<br /> Job Site Addrass: �'�C7 u.p,1,�?�•( �nv��L,� C��Q�,,,P,. t�U � ��
<br /> WiU this he a Parade ai Homes, Remodelers S owcase Homsdr�ther Oisplay��Hn�e� ec��� No ---�
<br /> __..,., If�yrs,n.�cipl evcn!pc►m1[Is raquircd whh Pdice�eperhnenl end C�'ry CbUnCil approval 60 days prio�lo Ule.e�l►M�I�,UJI�bua se cd will hrt .., ,...,
<br /> - - ._ i+c`qWled unlf;.�appliCent deIllonst/eies Sull]CGe►Ir o�+�Sltd p��lcing!a avbNublc. Nvn-portniHed ei�enlA wiU hcil f�•a/fowerl. . -'
<br /> COMTRACTOR l APPLICANT INFORMATION�
<br /> ►v�me: GZo rc��v,�e 5 �or�`r'rY�1a� , ..
<br /> Statc Liccnsc# ,�p.e-�9��� Expiratipn Date: _ .-
<br /> Le2►d CenifiCBtion Number: �� Exp�ra�tipn Oste:
<br /> --.._.. _...
<br /> r . , - prf 7978_ . . , _. .__ .._
<br /> or wo�k on honisa that wsro ConSbvG[ed OI't�
<br /> Phone: (ofFice) , �9�'�2- S�'� "3.��4,, fc:ell)
<br /> Mailing Address: - City . �.,�.��,G,' "LIP� .
<br /> Contact Person: Applicant i�: .n ra� � Homeowner �.u��,o�
<br /> _ _..r...,.
<br /> ----T - .
<br /> �Ert�ail-and/or Fax:. •. ._ . � ,...._ : ...,...
<br /> O�'+"� _..... "_,.' ..._
<br /> PRO�ERIY OWNER INFORMATION: - _..- --__ . _ _. . .
<br /> Name:- (�.�,�a eV�.s �,f� .t �Pv�� 1��.��_.. _. . _.
<br /> ,: ,: ... _.....
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<br /> � _ _
<br /> Phane{da�• q�'"L S•' g�� _
<br /> Ad�ress'. �;r '. . �C'pp� W. 'N` '"r' Ciiy. ZIP: ��b
<br /> EmaU a:nd/or�ax �.r►flv� �c�fLvh I�v�e� _�Q�p.b..C� G ' •G�iw.
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<br /> _. _.... ._..._...._ .. ... .. _ ...
<br /> PRO.lECT 1NF4RMATION.. : � .. � . ��
<br /> Type of Project: � Any carth movement may�eq ire
<br /> ��, iv� ,+,re� :, ,,:. I , 111CYND rzview 3 permlts:
<br /> D�nr(�) , , ' [�R�madel , ❑Water OAmage Minnehaha C►odc Wotershed�i�triG (MCW01� " �
<br /> 0+�Vi�dQw(s) �. ❑ Rcpai( . ., _ ❑Storm Oamaga 182Q2 Min�etbnl�a Blvtl
<br /> .
<br /> ❑Siding" ` Q Restoi�ation �Other. (specfly) (leepnaven; MN; 55:l,Si ; , �t,,
<br /> , ., . Phonc:;9a�,47.1.D5�&0
<br /> []Re•►oof ❑��ire Damaga Fex: fl52�71-0682
<br /> �w�.�°:f.,'FF�;,'��`;; , � i� . � � � � �WyY,1T�innefyifi�ei�k:.Q19
<br /> ve�all Pr 'ect Descnption• , �
<br /> • • ... _ . .. � , •
<br /> ��lf ptrd�Consiruct�oe Valuatloh of Project(excludin�land) .���Q=" ,�e_.�. _,_. .. . _.
<br /> �,a,,;,�I"'..�� ; , , . —
<br /> � pi����s�oc�Nov����ED!'C3EMEN W���,;� �� _ ._
<br /> �.�....__. , . . .. _..—
<br /> 9 p � ' q stcd by lhe Building Department;
<br /> i�l'7 ��r ; . . . , . I
<br /> �. i�'�Gertifle5 that the in(urmisiion s�ppUed is true and correcl to the best of Nis/her knowledgo. The ap�f'�cant recop izes Ihai tMey ,
<br /> ` xrts Snl�ly responslbin for�ubm;ning a ComDl�ts appllcatfon bo�ng aware that upon tailu�e to do so.the staf� has tiu alterriauve i
<br /> �- I �btn�tb rejea it until it is,complete: , , . : : �� ' :
<br /> e al! of lf�r•,inlomlyticn thal you 8re asked Sa prpVicle On tnis applice�ion ic dassifiad by State I�w as ei e,r prlvatP 0�'
<br /> �R'�`�f�", ilitl2�li91.' Privele.�8td i9 mlWrn�ti�n..wltiiGr go��prally cannol bP 9iven to tt�e pubfic but can be c.�iven to tht ubMct of IhR
<br /> r � ''' dala. Cunfid�,nlial d8ia is inform�li0�y WI►iCh g@nerally cannut be. given to either the public ar th+� sublpct of t e data. Our
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<br /> � ,�. P+,; <<nrrpx�sa �nd mtended us� af this in(c+rmation ls to annua�y uprlt+te our r,ecswsis and necords M ether govermm �tal agenc�es
<br /> �, � �..fe4uired l�y,l2�W. 11 you''''re(u5e;1�Supply th�ir�fr�rrr►alion,the aP Gcauon ma not De iss��ed. - ;
<br /> Applicant's Signature: _ , ' ' nat9:
<br /> l�asl�Dd�ed: 03-01-2011
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