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MAY-24-2011 13:16 From:GORDON JAMES <br /> City of Orono <br /> ` ; Bullding Permit Appli�catian for Internal Work <br /> {windows, doors, siding, re-roof, etc. <br /> ..��--•_;•• M�ilirey Adclreaa: .... .Q <br /> • //�''~g►�.�� I'O Box 6G Pc�rmlt nUmber. 020 <br /> //� � Crystal Bay,MN 553�:i-OCf6F Dot�roaeived: �- // <br /> l� � <br /> ��� " �� .. Sircet Addre��: ��by� _ <br /> \ � Gti� 2750 KeYeY Perkway Plan revieW fe9' <br /> �E9���/ I Oronu,MN 55:f58 p �j <br /> -e-�~' 1 o1S1 F@8: -� � � O . J/ <br /> Main: 9512-249�6W Fax: 952-249�4618 www.ci.orono.mn.u.a <br /> , <br /> This application forrn must be completed in tull a�d all r�qui�cxl inlcNmation must be submlhen <br /> Incompletc�pplication9 wili tie�stumed. (Pfease print) <br /> GENERAL INFORMA71pN: s - <br /> Jab Site Addross: � �Qy{ pgr .r�,i ` �0/1 u�Uy�{��_ _, � � �o <br /> Will thiR ba a Parad of omes, Remodelars'S�'rwcase Nom r o�her Dfsplay N e9 es No <br /> ll yes,e�pecial cvcnf m,�1s roquirod w/th Pp►�ice poparurmru w�tl Ciy Cn���l approv�160 day�prior to t�e event SN�QIe bus onnrn w�l bE <br /> requlred os8�ppleCenf 09mOnBbr91o9 9WfiCicnf�n�veg perlri�g!s�th�bab/C. �n-permitred ovoMs wdl rwt oer ep <br /> CONTRACTOR/AP UCANT INFORMATION: <br /> Name: p��p� ' � <br /> 5tale License�! ���� ��� Expiration Oate: � . <br /> LC�d Co�tification Wumber: � Expiration Oale, <br /> ('/or w�erk on Ao that were con�tnxbd prlor ro t�7e• ' <br /> Phone: .3 - �-{�t�l- �✓L17 (office) �g I 2 - �� —�Z.�,_, (c�ll) <br /> Mailing AddrE�s: Y � '� City ;ti ZIP: � <br /> ContBct f'erso�� � _ _ ApplicaM is: o M Finmenvuner tc�Ki�a�Qy <br /> Emeil end/or Fax: ' ��,y�,�5 ..CG'7�+'� <br /> PROPERTY OWNER INFORIIIATION: <br /> Name: � .e.�s �..n a �x� <br /> Nhori� (day): � � <br /> Addr�ss. W • '~` _'1:_... . __ Gity. ' ZIP: �(�,b <br /> Fm�il andlur Fex ^ ".r�o+��q� ,G�_b �cvr� <br /> . <br /> PROJEGY INFORMATION: <br /> Type of ProJeet: � • ---- •-•-•--• Any earth moveme�l may quirc .. <br /> C�6aor��� (�Remodel ❑WAter Damage MCWD rov10w d,pertn ; <br /> Minnehaha Crsok WAlBrSheE pls�IGt(MCWD) <br /> [J Window(s) ❑Repair ❑Slorm Dama�e 1g2p2 Minnebnka BI <br /> ❑Siding II ❑Restoration ❑Olher: (specity) 0«Vt���en,MN 553 1 <br /> Pl�onc: 952�471-05'J <br /> Q Re-root ❑Fire Damago Fax: 952-471-OG82 <br /> www.minnAhAh�nrn�,k <br /> Overalt Pr 'ect Des riptio ' ������� � � __ <br /> Estlmatad Con�tru loh Valu ion of f'rojesot exciudin land) � � <br /> APPLICANT ACKN WLEDGEMENT: <br /> Aqrees to prdvi c�ll in(o�mation required or�reyuesled by lhe Building Departmer� � � <br /> � (RAilies Ihat the information supplied is t�ve and c ect ta �hc best of hiy/iitl� kr�rl�clye. 7he applicanl re goizes that they <br /> e <br /> are eul�ly respa'isible for submining a cc�mplF+„ta Ilcatl4n belnr�aware ihat upOn failu►e lo do So, the St2tt h S rw 811ernat�ve I <br /> but lo r�jeG it unUl il is camplale: <br /> � Some or all of g fnform�llion Ihet yau are ad m�1rcwlAe �n thl�AppNr,aOnn is�IaR�ifi�d hy St�te law a� either private or <br /> cantidei�tial. P" al� daW is inf io� generally cannot bs given W tne publlc Du� can pg 9iven ta subject of ihc <br /> d2t�+. Cantide lial data is i mation general cannat be given to either the pubQc or tha RuhJect f the dala. �ur <br /> K�urrUl�rr anA inkended use f this into � IS lo - nually update our records and reco�ds of ether govem ental agencie� <br /> r�:quired bY I�w, If e lo su,�ply,„i_ ,_ ,���¢ , ,tlje e,pplica' , ,, e not be issued. <br /> Applicanf's Signature: Date: � Z f <br /> LatSt Uplldled: �3-01-7Q11 '' <br />