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Citi► of Orono <br /> BLAichng Permit Application for Internal Work <br /> (whdaws, doors, sld% re-hoof, etc.) <br /> Meifarp Address' Perrrel number a(7i <br /> *0 4, PQ Brix 56 <br /> Crystal Pay MN$5323-0066 Date Fete*ed <br /> 'f Y <br /> Sueft Ad�sa_ <br /> Recego ej tty <br /> r 275X1 Kelley Parkway Plan ra-.iew fee <br /> ►� .y `� Orono UN 55356 <br /> 5' <br /> Tool Fee 7_ <br /> Main 952-24946W Fax. 952-24"616 wvrw.c orotto inn us <br /> —._ fiii application fttrt'n must 3.k :r tUti ;)rt.t a!f•-y+jUr #6 trifoirnallon must be submAled <br /> Incomplete applicadions wilt be returned. (P)ease print) , <br /> GENERAL INFORMA710N.- <br /> Jab Site Addrasi: 1,50 NN�GW6 MY0 MWY1b" <br /> VMthis be a Parade of"ease.Remodefen Showt:arse Home or other Dtacplay Home? r Yes No <br /> Myll A C4i�R+R.sr4'�NRr'm1l MuJRC�i►'1A lID4Y i'#r'!Jr rtr;Nf AreU :dY .'.4runt d.t rtC�J!t �,l}A�rtlrr! r±iC Cycrin Sbtl +k pct. .'. 'F r:fJ <br /> elt�Yred varrss i�ClkirK�irrnitarabJtes SuA'Klrnr on-a!tr y3r+w�}�ilriBitY! Alba-perA�'e,7 evrets w•w4 not Dr JACwrd <br /> CONTRACTOR.,APPLICANT INFORMATION: <br /> NamrGJA W I W ���odf l i✓1� I fir✓ <br /> State License # ZpZ , ' D Expiratran Dale '-5 112-6 13 <br /> Lead Cvl&ration Nuntl'.er Expiration Late. <br /> OW WWk on htwrns iMac wars corns Csw darAw to "T# <br /> Phone (office] f � ' 1.. <br /> 5 Z -2 �1 -�`_ (ren)wi <br /> MaAng Address n lfrxv fi 71R <br /> Contact Person DELL q Chum _ AF.plicant is r•ntraety ) rtrrteawnef lc*vjo,orvl <br /> Email andior Fax / IA C . 1 kb <br /> PROPERTY OWNER INFORMATION., nn 1 <br /> Name K Q'� 1 Yo l I U W, <br /> Phone (day) - LCU -7 <br /> Address. 5� 01�� ShyYe DYIV-b City Mn vi :-IFS <br /> Errtag and/or fax <br /> PROACT IWOtiMATICIft <br /> V—" wno11ae■ret MW nmpba <br /> YCMD re mew i pariahs: <br /> (j D-301W C 1 Rernocle. [D5�*Mater Dama3e MinfishaDta Creek INa tirtitod Dretnct(MLWD? <br /> 0 WWrdow(sl D Repan 0 Storm Damage 18202 Mwmetw*a Blva <br /> Q aid&V D Reitorat,,-in D Omer. twtclfr; aesphaven.MN 56391 <br /> Ptuone 952.471,050 <br /> 900-roa ❑F".a ownag" Fina. 952-471-066 <br /> www ftiviolgowrook r}re <br /> Overall Projeci Uaocrriptlon: <br /> BVI 5n <br /> �olirneMl+td CorMst+ruction Vaivatiorr of Prt+jtct j+:xtluding tared) ; <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agr**s to prsivide aA Ir tr it try the Building 0epartment, <br /> cerlil%es that tn9 Information supplied is tyre an,i correct to tine beat d tws►he+ kmWeage The appwcar4 recognzes that they <br /> are solely resirronsib#e for suvmrttmp a carnptete application being aware that upon failure to do sa. the staff has no atternat►re <br /> bul to rewt rt until tt Is c ompi*­?e. <br /> • Sonne or all of the Irrtorn-Qmon that you are asked to provide On th3 applKalrore r$ ctasSif+ed by Slate taw as either prwale of <br /> cordidealLal. Pfivale calla is Worm0on*arch gen#ratty canna be given to the publ+t but can be 9wen to the subject of the <br /> i <br /> data. Confide,.'rai data is mfofine .,...,rt, getwallr cannel to gryen to edner tris public of the !swiett of the data Our <br /> purpose anis -tu:t usd cf Rnr s t ;n •5 In annually upeat4 our retool and recoics of other ger err veru agonots <br /> :__ r& it t:c.•. ( .„�i iePu a!4 ', •t t r ::rr.tho a pheation ma not be Issued <br /> Applicant's S►gnatuf,� 'C�f �'� � _ gate 71)2-111 <br /> LAW.t11 ew '33-W m r <br />