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MAR-15-2012 14:06 From: � To:+9522494616 P.2�2 <br /> . <br /> r ..- -. i <br /> I <br /> City of O�ono <br /> �'uilding Permit Applica:tion for Internal Work <br />� (windows� do�s� siding, re-roof, etc.) <br /> r,-= --.--.� AAmiliag AAdreru: Pemflt numMr —� � <br /> ,//`�d,�`\ PO Bcx 66 <br /> /0 Q Crystel Bay�MN 55323-0O6G oate rec:eived: / .�'-� /a-- <br /> ` <br /> i � � <br /> streetAddrqss: Recaived ey: <br /> �'�q �'�� ZC)mtio,Ny55355 y Plan review fe — - <br /> _{ �'= � <br /> -�-�R~ ,-���: l �o , �-g <br /> Mein: 95$-24}a600 �r�x: 952,249-4616 www.d.ora�o.mn.us <br /> This ap�blicadon fomn must bo cempleted in full and�all required informatbn must be submilted. <br /> Incomplete applieatiotis will be retun�ed. �Plesse print) „ <br /> GENERAI INFORM�11TIpN: �J � <br /> Job Site Add�ess: ; � . �}Q Jv� <br /> Will thi�be a Paradp�f Homes, Remodelers S o�waase H r othar Display N 7 es No <br /> K yvs:a specie!even�pem�lt!a roquirod wlfh Poacs Depemr�and C�ry Courrcx upprordl e0 deys orbr to tne event. Snuele su sorVies wi71 t� <br /> rovulred kx�wxs�plicaru cx�rnnnsm9res aWrtc�cnt a►,spe parking k�evaUsbk. NanysnyKstl events w�l nat De a d. <br /> CONTRAGTOR!A�+PUCANT INFOR�IIATION_/� � <br /> Name: ��1orr.�Or��r�►�l��� �--Oh.S_f�1n <br /> ��ate�Icen�c# ! ��•� G� ' Expiraoon Dete: _ <br /> Lead CeRlfication hJumber� � �.. � � Expi►ation Oate. <br /> Nor work on Aonhes that wara epn9Wcled pl'fa'to 797H --...~ <br /> Phone: ; (�� • _ (oFfice) (c��'Z • Q�'Q —?�,;C� (c:ell) <br /> Mailing Address: ;' _p , R �ity r, �t��4i� �I': '�. <br /> Conlact Perso�: ;� ' Applicant is: o tr r Homeo er �ckus ono) <br /> Email and/�r FaY• W� „ �j��,s _Ca1'� <br /> PROPERTY OWNER INFORMATIONi 1 �/� <br /> Name: ' � ...f II�S �^..1'ti��1nAP��' Y�'A.r��... <br /> Phone(day): ��s- ' g.��,� __.. <br /> ., <br /> Address: �.�.Q.. .L"-7 . '� -r c�i . �w: S'S�lb <br /> Ernafl and/or Fa�C ��tfl��� p�- r�o,�,b.r� � � �G vv� <br /> PROJECT IN ORMA710N: <br /> Type ot Project; � A�ey earlA moveme t may requlra <br /> 111CW0 review pormits: <br /> ❑Door(s) �Remodel ❑Water Uamage �;nnei,uhe Creek Walers d Dislrict(MCWD) <br /> ❑Window(s) ; ❑Repair ❑Storm�ama�le 18202 Minn� nk8 Blvd <br /> I"1 s�a�r,a ❑Restoratlon p a�,�:�Sp�y� ocepnovc��, N 55391 <br /> Phonc: �62 71-UGJU <br /> �R►3-rnef ❑Flro Damog9 Fax: f362� 1-O('�}2 <br /> eek.ora <br /> Overell Pr '~ct Doscription: <br /> Eatim�ted onstruction Valuatlon of Proje cludin Is�d� � p � <br /> APPLICAN ACKN0IN�EDGEMENT• <br /> Ag s lo providr�all infuRr�alic�rt rey red or r uested by Lhe Buildin0 Departm�n� � <br /> � CeA�l1es that thc information suppl� d is Gve nd corred to Ihe best af his/her knowledgc. Thc ap licant recognizes that they � <br /> are�olely raspons�ble� ' A Comp e�pp�l�atlrm be�nc�aware that upon tailune bo do so the staff has no alternalnrC � <br /> buc�o reject it unU cemplete; � <br /> � Sor�he or all the IMormation aS you asked to rovide on this applicaGon is dassified Dy t�itr law a� either p►Nate or <br /> ca'tideni' . Privete date is I mtaUon ICh gene ly can�ot 6e givien ta the pubtk but cen b giv�en to tha subject of Ihe <br /> da�a. didernial date is in rmadon kh qener cannot be glven m elther the pu�lic or t e subject of the da�a. Our <br /> puj�wsa .�nd inlencfcxl use of is:infp Is to nuslly upeste our necords anC records of Iher govemmental agencies <br /> r r ui�ed law. If u refu e a su I irif tl e a_pNc2lion may not e iss . , , ,.._„__ <br /> AOpliGant'� Sic�natu • . .._ .. �ate�: �..._ . <br /> I��UPdetbd: 03-01-20�11 <br />