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J:I-lo-2�11 OB:05am From-CITY OF ORONO +A5224A4616 T-058 P.002/002 F-1T0 <br /> • '� —� �■ ���v <br /> " � Building Pe�mit Application for Internaf � <br /> (wjndows, doors� sidin . re-roof etc. ��r� <br /> Mellin0 AdOAas: � ) <br /> O�"�'� Po Box 66 Pumk number: — D � .9 <br /> � Crys�l eay,MN 35323-0088 Da6B rece;ved: <br /> � /. <br /> � � Stivet AddiaBs; R����, <br /> 2750 Kellsy Psrkway <br /> ��'� Orono.MN 56356 Plan r�view{e�: <br /> �_� <br /> M81�: 95Z-248-4600 Fax: 952-249-48i6 Total Fee: ���f3� <br /> Thfs application fatm must he�pmpleted in tull an���� � <br /> Incomple�app�ications w111 be�W� inform4tion�must be submi�ed. <br /> 4ENERAL INFORMATION: �d• (P�eere p�q <br /> Job 8i1r Add�aa�: �,�� <br /> Will this be a Parade of Ha�nes� Rsmodelers Showc.asa Home er �ther splay Home? <br /> �1Ms.�speNe!swnt pa,rrit/a roawas�d�,Aa/,bs o�pemnont ana►C!ry GounCil YeS <br /> ro0u�rsd a�fksa 4AON�anl ahrhan�hradsa a�A�cient on-sUe OarJrinp fs a�N.bl�s. ��w��he srenf. Shuffla eas ss,viae wid be � <br /> CONTRACTOR/APPLICANT INFORMAT1pW: ��•`�'�""�^or ea e,obw�t <br /> Name: �e� B <br /> Stste Licenae# ~— Y�dersen <br /> Phone; �-- 1920 Cpunty Road "C"West � �iraYon De�; <br /> Mailing qddress: ---- Roseville, MN 55113 ��� <br /> Contact Person: — " Lice�#20130983 C�� ZIP: <br /> Email and/or Fex `� 65]-264.47'77 �t�� Contracto� I I�omeown�� <br /> � . tcau•o�.� <br /> PRQPERTY OWNER INFO�b� N, . <br /> Name� �� <br /> Phone(day): � <br /> Addr�eas: <br /> Email and/or Fax � Ci : <br /> ZIP: <br /> PROJECT 1NFORMATION: <br /> TYpp of Pro)sct:'�{p <br /> ❑ Door(s) "` c�., J W i� ��!V �p1'I('� 4ny MC mov�enont m�y roquirs <br /> ❑Ramodel ❑V►l�ter�arnape • WD rovisw�p�►rn�b <br /> C]1Nindpw(s) <br /> �R��r ❑Storm Damage Mi Aa C�eek Wate�ehed Oiatrlct(MC1AIp) <br /> 1a2a2 Minnetonke Bhrd <br /> ❑Sidin� ❑Restoralion <br /> ❑01her� (speClfY) �Phevcn.AAN �6381 <br /> ❑ Re-root Phcme: 952471-0590 <br /> ❑Flre Damape F�x; AS2-471..0882 <br /> dverall Pro t D�sc�lptlon: �acboa� � <br /> �ma�ed Conatruetlon V�luation ot Pro s�t(excl�,din landf : <br /> f—� <br /> APPLICANT ACKNCWl.EpGE�AE�: <br /> ' A��s�P�lda aU iMorrrtatbon requa+ed or� uested b the 9ui1clln Do <br /> � y 9 P��tment; <br /> • Certilles th81 the Informatl� wpp�ad Is truo and opmect to�he pest af hlsfier knoMA <br /> b��`�eh►�esponslble lfor submltting a compl�apppcatlon being aw�re tha� °�. 1'po applicant recegr�es thet they <br /> Ject it untif it ia c�maeee; upon taA�re to do so �e steff has no e{temativ. <br /> • Soms or a11 of the infmmaqp� tl�a�y��ag�@d to prov�da on this aPPlication is dAa�d <br /> mnfideMial. Prlwdte dat� ie iMnrrnaUon wh{ch genete�, �� be glven lo the publlC but can <br /> �. Confiqenbal dsla is fn �' S� ��eRher privete or <br /> �upose end Intsnded �a� �"F'�� 9°�ranY �annot be given tv efther d�e �a�Ven to the�ub)act o�the <br /> ui�ed � of�is informadon is 1�snnually updata our rooprds and ��� or the subjsct of U1e det�. p�r <br /> law. If u rafuse b�u ihe information r000 racwde oi other pqyernrnental apenclss <br /> tic�ma not bs letuod. <br /> �pplkaM's Signature� <br /> Date: _ $�V 1 <br /> �st�: 05-C4.zoos <br /> Z �d 06I94G9iS9 3�IAa3S lIW2l3d Q 9 S 1'1 96 :9T iT02 8T Z�C <br />