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. �/" n� <br /> � /'�� <br /> , , , � U" <br /> Uv. <br /> � ��►1 <br /> �C�ty of Oro.no v� �� <br /> ' ; Buildfng Permix ApPli.ca�ipn for In.temal Wo�rk <br /> � windo�, doors, �siding, re-roof, etc. <br /> :�� Meding Addr�ss: ` <br /> Q �� Permlt nurebar. <br /> O�g► .1�0 � �6 <br /> crye�ai ssy.MN 55323-0066 r�a�rs reoetved: <br /> "' Str�r:f AcVrJrCs.s': Received Dy: <br /> � ,. <br /> 2750 Kerey Parkway plan review fee: <br /> � drono,AAN'5535E3 <br /> .L` �p��, � <br /> :_�. � ,-dd Fea: / � .S/ <br /> M3in:i 952-249�600 Fa�: 952-249-4816 www.ci.oronb.mn.us / <br /> Thls,BppNcation€onn must k�oompleled in 1ii0 end'ail requlred Infortnatlon m►�t tie�ubmi ed- � <br /> Incomplo.t�applicatlon9 w1116a ntun�ed, (P/eaae print) " 3 O f <br /> +f3ENERAL INF.Oi#MATION: ^� � � <br /> Job SIle Address: �.(o'�b. P -Q1� n,� ..r S��n� 4��� <br /> Will�thl6.he a Par�ade e1 No�rfes; Rernodol'ars�Sl�.�,casi Ho� � � r "�r GI�p1ay�H�e? . No <br /> M y�s�s spsua/e�ant pennp Is roqulrcd:w�th�PoR�Deperfinent end Gry CouneH�approKal 80 days p�ior to fna avent. Shud�e us son�rae wi11 br <br /> �1Q�J��4d t�+rk/5b�7p�AI d9►/JO�Od SfAIICIOAR OA��R�f1flg IR AV9I�qA�G. HOA"DCf/INMOd CVC�WiW/lOf 6A . <br />' CONTRACTOR/iM�I.IC�INFO MAT10N: <br /> Neme: i Cr�lerdot'� • , e �pN, ~ � <br /> State License# ; Expiralion Date: � <br /> .^ <br /> Lead Certificatior�Number: ��� Exp�ration Date:, <br /> (�Or wo1'h oA hcf ines fha�were.ctrn�truc p�Ia'M 19TA � _.. <br /> Phone: � 3 . . (oEfice) .1 Z„- g$��— Z,CE (cell) <br /> Mailing Addrsss:i 3 plt ' �� n Z P: - <br /> Contact Perso�: i Applicant is: tra �hlomea er �c.��.onol <br /> Emei1 and/or Fa�: _ • _ Y _ <br /> PROPER7Y OVI+NER INFORMATIQN: 1 -/� <br /> Name: ��e�S � P���G�AN.�.� �h2r�1� <br /> Phona(day):� ��-.� • g.... � .. <br /> Addresa: u�. y'; Cit IP: �(�,b <br /> �� �1�;�. .P� <br /> Email sndlor Pa I t � ry„� <br /> � w.... c1 C GG.. <br /> PROJECT IN ORMATI'ON: <br /> 1'ypa of Pro eet:I �� � Any earth moren�n may r�quli.e <br /> ���KR) I�Remodel ❑Waee�Damr�+ 11CMfD review 8 potmit6: <br /> D Window(s) � ❑t�e�ir n�i�ne►,ar,�►c�wa�erg Dist�ict(MCWD) <br /> ❑�St�ortn Damege 10202 Mihneto ka BINd <br /> 0 Siding i ❑Restaradon Other.(speclfy) � L1e�.Bph�ven,M 55391 <br /> Pl�ne� 952-�1 1-0590 <br /> Q Re-roof []Firo Damag� o►� Fax: 952-47 -f18A2 <br /> k. <br /> Ovarall Proje Do6criptbn: ��� � <br /> Eatimotod Co s�ueNon Yaluaelon of Pro" ct oicc�ding lailt� S Q Q <br /> APPLICANT CKNOWLEDGEMENIT: <br /> Ag�ees•i o proNde all infam�tion required or roquested by the Building Do�artrnent; <br /> � Certifie lhat the intormati0n Supplied ES true end eorract to q�e boEt•of hielhar knvwledge. Thc appl nt recagni2es that th�y <br /> q� <br /> are sol ly responslble For submltsing q Complpte eppl vh being eware that.upon failure lo do s�, tl� 9taB has no alternativ� <br /> but w r�iect it�ntil it ir cOrt�ple�le; <br /> � Snme �r all of tne IM`a�madon mac you ar.e d ca provids on Ihfs appllcapon Is classilled by Sr� law ss silher priv2hB or <br /> confldamial, Private dota i�info ' generoly cannot bs yMen to•ttle publfc but can be g' n ta the subject�f 1hC <br /> data_ �enNel d9t� Is I atbn gene cAnnat be Qiven to elthe�the pubUt ot lhe ub)ect o(the data. Our <br /> purpos AnA IntBnQed u of this in , i�n IS t f.li.lallx updote ou�rOcofd6 end f.eoords M o mmc�ntad aqoncios <br /> r ui law. H xou R�se s �e ic�form �on the a lics�on ma not be issuecl.,_,_____,__ � <br /> Applicant's Si�nature; ��! Tp�te; �/r <br /> last Updated: �01-2011 <br /> s3wdr Noaao :w��� �a:ii itiea-sa-�nl� <br /> � <br />