Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
, � <br /> � <br /> C�ty �of Qrono <br /> �IBullding Permit Application for Inten�al Work <br /> (windows, �doors, siding, re{oof, etc. <br /> t Mailing Add,ass: Pe���q�mber•. D / D> <br /> /.��,� PO 8ar 66 <br /> /O. Q CeYstal Bay,MN 55323-0066 D��rocelved: <br /> � � SheetAddress: Fieceive0 Dy: <br /> �� 4� Orono,�MN 55358 Y Plaa rQyiew fee: <br /> �=.�' I Total Fe�: � �8S �� <br /> Main: 952-2dg.�6� Fax: 952-249-4819• ci.o n.us <br /> This epplication form must be complete�d in full and all requfred infom�atbn.must b,e submitted. <br /> -L' Incomplais•applicatlons will be retumed. (Plea,se p�lnt) <br /> .GENERAL INF.ORMA�TION: ` �� <br /> Job Site Address: 0 2 <br /> WIII thls be a Perede ot Homes,Remodal.ra S,awca9e H r oU�er Display H ? No <br /> If yes,e spOt16�eve»t p�em►it ie�equired wdh Po�i�s DeperbneM end Clty COur�eppMv816Q da,ys prior[o Me eve/q• Siwrfla bua 56 Mlfll be <br /> •requ/red�appYcenr�monaorafrs a�nt an,aJre perkfng Is avabt�le. Non psm+itted ovnn4 wiW not be eUowed, <br /> CONTRAGTOR l�APRUCANT IN�O MATION: <br /> Name: G o�c� � �"' r <br /> Sta1e License# Expiration'Dste: <br /> Leed Cert�ication NuMrbar: � Expiration�Date: <br /> (!or work oe hoi»ms�thst W�ere con�truerod pi/o�to 1978 <br /> Phone; � '3 - (office) 1.2• $$r{- 'Z.l.f iceH) <br /> Meiling Address' , city �;,� zIP: <br /> Cont�c4 Persa�: Applicant is: 'ba r Momeowner tcMc�.o�e� <br /> :Emeil and/or�ax: ' C .._ <br /> PROPERTY OWNERIINFORMATION: <br /> Name: �' � R. Q P.ar..'� .. <br /> Pho�e(day); . <br /> Address: u.� . 3 � -,r;' cit . zIP: �{Ib <br /> Email end/or Fax � ► k G •G <br /> � PROJECT INFORJI�ATION: My��p,oy�nt may uirs <br /> Typ�•of ProJeCt:• <br /> ❑Door s �I 0 Rernodel ❑Water Damage. MCWD r�1e'w 8 porrt�,� : <br /> ( 1 Minnehaha Creelc.Watershed Dis �(AACWD) <br /> p w��i6) O rie�+r ❑Storm Damage �e202 Min�tonka 6tvd <br /> p Siding p Restoreaon p ocner:(�ty) p��e�g��71,�p gp <br /> 0 Re.r,00f I� ❑Fir�Damege Fax: 952�71,0662 <br /> www. <br /> Oversll Pr �CG'�D6 �pLlOh: <br /> Estlmatad Constru lon Valustlon of Project(exdudin lan � <br /> APPLICANT ACK EOGEMENT: <br /> Agrees ln provl e all informatlon required or requested by the Building Department; <br /> � Certlfles thet ihe inFioimedon�pplied is We and rect to Ihe best of hia/her knvwledge. The appllCer�t reco nizas that they <br /> a�a solely res ble for subm�c�ng a canple a Ication be►ng eware tlt�t upon Failure tv da so,�he staff na no aiteme tive <br /> but to reJeet if ntil it is GQmplele: <br /> � 5ome or all of It►e IMormatlon that yo ro ed fi prov�de on this applicstion is classified by State lew as ither'prlvate a <br /> oor�fideMidl- vate ' n wh gener y�annof pe 9iven W 1Ae public Dut can be gnron to subjecl of ihc <br /> data_ Confido�ti te Is info n wh pane ce►not be ghlen tp eitherth� pYhllG or the SubJect o 1t►e dats. Our <br /> purpose and'i ed use,of I rm a7 Is te, nually updete our records and r�ecords of o g ntal agencles <br /> uired �aW. s irrF rm n a Ucalion nok he issued. <br /> ApplicenCs Signaiure:l na�= � ZS <br /> Last Upaated: 03-01-2011 <br />