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� <br /> -2011 21:26 FROM:TREBILFOUNDATION SYS 3205938720 T0:19522494616 P.3�3 <br /> o�l� I� City of Orono <br /> 6uilding Permit Application for Internal Work <br /> (windows, doors, sidin , re-roof, etc. <br /> Mailing Addr�as: permit numbec o�/ —D O <br /> O�O�O PO Box 66 <br /> Crystal Bey, MN 55323-0066 Dete receiwd: � <br /> Sheet Adtlress. Received by: <br /> �tv,� o���� Orono MI'N 55356 Y Plan reviaw f�v: . <br /> - Taql Feo: <br /> Main: 952-249-4600 Fsx: 952-249•4616 www.�j�rono.mn.us /� � �� <br /> This spplication form must be completed in full and all�equired information must be submi�teda� O� ' <br /> Incomp{ete appllcatlons wlll be retu�ned. (p/ease print) f - <br /> GENERAL INF�RMATION: � � <br /> Job 3ite Address: � j> ' p� <br /> Will this ba a Parada of Homes, Remodele�s Showcase Home or other Dlsplay Home? Yes No <br /> 1I yaa,e speelal evsnf ps►mlt la npubsd whh Aalics Qepartment snd GTy Coundl epprou�l 60 deys prbr to Nie�wnt Shuttle bus ssnrke wUl be <br /> Iequ!!ed uAbSS APOIJCA�I�d0lIf0A5N8�98 8lMIC(011f 0!I-6ItB 09I�NRC 18 BVV�IlObIB. �VOIMaR171�(�OVO/1!8 N�ll I10t bB B�OWipd. <br /> CON7RACTOR/APPLICANT INFQRMATION: <br /> Name: 1',�0 =Tr�o�i� ����.f�S�L�r, St�crl�nrL� <br /> Siate llcense# ����4�q ' Expiration Date: 3� 31 - 0101 a <br /> Phone: q - office cell <br /> Meiling Addresa: C� : 't ZIP: <br /> Contact Person: �plicarrt is; Corrtracta � Hom�owner �ciroio ono) <br /> Eniail and/or Fax: s , <br /> PR�PERTY OWNER INFORMA'1'ION: <br /> Name: �� <br /> Phone(day): q�a��g�� �� <br /> Add�Ss_ y1�51� N. Arr.r. Dr_ , Cl�i:�r�� ZIP: 553(e y <br /> Emaii andior Fax " � <br /> PROJ�CT INFORMATION: <br /> Type of Project: Any earth movemeM m�y requtre <br /> MCWD rovisw&pennita <br /> ❑000r(s) p Remodel D Watsr Demage <br /> Minn8h8he Creek 1Net9rsh9d pi9bnct(MCWD) <br /> ❑Wi�dow(s) �jtepeir ❑Storm Damage 18202 Mlnnetonka Blvd <br /> Oeephaven,MN 55391 <br /> ❑Sidnp ❑Restor'�tion ❑�ther.(speclfy) Phone' 952-d71.0580 <br /> p Re-roof Fax: 952�t71-088Z <br /> ❑Fire pamage wvvw.min��h�hac��k.oro <br /> Overall Pro'ect Desc�i tion: 'c�n cu,rc. <br /> Estimated Construction Valus#ion of Project(axcluding Iand) S � �pp_ p Q <br /> � <br /> APPLICANT ACKNOWI.EGGEMENT: <br /> • Agroos to p�ovido all ir�ormetion requirad or requested by tho 6uilding Depardnont; <br /> • CeRifias that the information supplied f� true and correct to lhe best oI hismer knowledge. The applicsnt�ecognizes that they <br /> are solely responsible for submitting a complebe applica6on being aware that upon fallure to do so,the staff has no altemative <br /> but t0.c'BjeCt it urrtil it ia Compl9te; <br /> • Some or alt of the information that you are asked to provide on thls appAcadon is dassified by Sfate law as either prlvate or <br /> confidentisl. Private data is informetion wtiich g�narally cennot be piven to the Dubllc but pn be given bo the subject ot the <br /> date. Confidential data Is Inbrtnation which generally cennot ba given to aither the public or the subject of the data, Our <br /> purpose ertd intended use of this informatlon is to annually update vur records and records of other govemmer�al egencles <br /> uire0 b law. If u refuse to su I th�in(ormetion the a lication ma not be issued. <br /> � ' 9 <br /> Applicent's Sipnature: � ;������U,r, �ate: I/N I/j _ <br /> �� T <br /> Lasc Updated: 03-Os-2006 <br />