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<br /> ' City of t3ra�o
<br /> '8u�lding Perrnit AARiication for In#ernal itlt�►rk
<br /> � �winclaws,�tc�ors, sidin�, re-roof, etc.}
<br /> _.:_.
<br /> -m.-� hfe�eg Adatm,sar pertYdC Dumber. �� � �
<br /> .�,Q„� � - RO Box S6 '
<br /> � �: I Grystai BaY.MN 55323-0(�6 Date received: —
<br /> • � '' Sheet Addness: Fleceived by:
<br /> ,�� 275C�K�y Pa�icway Plam nevbw#ee:
<br /> '���� Orano,�+iN�*
<br /> _- -��F�: � 3 5�',
<br /> �:
<br /> M�n: -249-46f30 Fa�c 952-�99-4818 www.t�.orano.mn.us
<br /> �ffii&a Ncation form must bre comple#ed in fuU and�aU t�qu�ed infc�rmatFan:must be sutxnitted.
<br /> Mcompiatc applications wilt be,refur�d. {Please prfntj
<br /> ls�IERAL Ifi��tMIA'ThaN:
<br /> Jcsh Site A,ddt�ss,: � S' f,�h,' �
<br /> Wilt tMs be a Pa ot Homes,Remod�tsri�S �wcase Hv ' r�d�es dbpiay H ? es o
<br /> N�s,a s�a!e�e pe+tnh'is re�quired wlth Po�e Depar6nerrt er�d�y+Coundi ap�xwat 60 days pr�or to the evertt: Shuttte bus se w�!be
<br /> nsqurred pMess apprrce,�r derna�ar►saes swRc;e,n on.slra ve1►kfr,s rs avaus6le. M�,►parrevelstr e�er�ia w�,wt aa asowea.
<br /> CANTRAGTQR! PLtGANT INFOR�iATIQN_
<br /> M13amec �l`�,p �E, t''4
<br /> State Lic�nse# Expiratiora De�': ,. ..
<br /> Le�d Certification N ber: � Expiration EaBte:
<br /> �..__ .....
<br /> (for wnrle on ho thst wate eonsb�cted pr�or tn 1978
<br /> Phone: (csffit:�} �'�. g',�Q- '�,,' {c.+eN�I'
<br /> �AAaifing Address: , City 4;,,� ZIP: '
<br /> Cantgct Rerson: APWicant is: ' o tra Hameowner �e on.�
<br /> Emsil andlor Fax: •` _
<br /> PROPERTY OWN�R INFORMATItiN:
<br /> Name_ ,�"" � ,� evt.-'C„
<br /> Phone(day}: .
<br /> A�dr�ss: W. "+'�` `t' ' Gity. ZIP: �{�.�
<br /> Emait andlor Fa3c ' .��
<br /> PRO.fECT INFO MATIDN:
<br /> Typo of Project: Any earth�nuvement'maY req
<br /> �Door(s) �Remodei �Water Damage MC11�re�rie�v�perte�itss
<br /> Minnel�►aha Creek Walersbed f�trict D)
<br /> p windo��s} O�,air , p swrrn oam�� �azo2 ru�n�s�r,�cs s�va'
<br /> zo
<br /> ❑3iding [J Restoration '' [j 4ther.{spec}4y} EleeFhB�en,i+�t 55381
<br /> Ptwtte: 952-471-0590
<br /> [j Re-root ❑Fire Damage Fax: 9,42-d71-0682
<br /> arww.�sin,�i�k.�
<br /> fAtQ�li Pr e�D �'uliOn; ' .,� ,,,,,r
<br /> Estimafed Gor� dian'Valuatk�n of Projact excluding landj S' •:r �
<br /> APPEICAMT AC NOWL�C1(`aEMENT.
<br /> Agr�ees io p uxi�all infar�rnetion r�quired ar requested by the Build'aig t7eryaf[men�
<br /> � Certifies tha�t the infcsrmation supplied is true and ecxrect to�e best oi IvaJh�ks�c7wledge. 'tttie appl�aot,recog that they
<br /> > are soleiy , pcx�sibie tor submitting a canplete appEtcatFon I�tng,�ware that upon fai{ure to do so�the staff has ' al�mative
<br /> but to rejeCt it unfil it is ca�npfe�te;
<br /> � Soma or all of the informatia►ti that you are�asked to provide on ihis epptication is Gassifred by State law as " er private ar
<br /> contiderrtial Frivate data is informatian whic;h 9eneral�Y c�snot be�vsrt ta the{wbFic hut can be given to the ot 1he
<br /> data. Gan �ta is i�d�mehan which 9e�alh+c�r�wt ba�van to eqher the public or the su6�ect af ' d$ta. O�u
<br /> P��P� fr�nded use t�tttis 1n#ormatio� �to annually update oix r�ords and �cards of atl►e�govem nt�age�cies
<br /> ree uired law: If rou reiuse ` #�e i�fOrma li�e a " �csn ma not tias issued.
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<br /> APPficant's Signat�re_ /%"✓Y� Date: r ' J
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<br /> Cast UDdated: 03-01-2Q11
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