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Orono <br /> Bufldfng Remit Appffcafi on I> '� I aintenaa'ce'-1 R®pincemant I Ranovatfon <br /> No structural expanzion. 0n1windows boors, aid In re-roof, etc. <br /> Melling Addr ow ,•; ';... :' t; <br /> P-0 Ba 8e <br /> Crystal PAY,MN 1515923-0088 <br /> F. <br /> Street Adds I", <br /> $tai,' RT^ ?.;d f�J' ''� `•L;. <br /> ' 2780 K II Peryway <br /> Orono,IN 65366 <br /> Main: <br /> b12-249-4aoo Feil:': -2 18 + <br /> This application form must be•tem leted In full and all required Iftrmnitbon r>nust be subxini <br /> Incomplete spp I*Mons will be returned. (Pleese pi lbn) e� / '� <br /> GENERAL INFORMATION: (2 <br /> Job Site Address: (y Q ��Q�� <br /> INll I thiel lets.a Farads of Homes•Refoodsl� howcusO.Horri�s or other.Display Homs? es No <br /> K yam;a spealal event pemnit is n*tquiusd f�DNCs.Lfa and ft Cd0d eppnava160 days pry fo Nie event .8huft bila;•sentb a99 bs <br /> FW"d unless epplfGsnt darnonetr 02 t&mfte Pm%h d i*vwW9bls. Nay-parmOtad etronle wttl not ba alta4vad. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name; A'C �co.. <br /> State License iratlon Date: ) / <br /> Lead Certification Number. - —I Explrtrtion•Date: <br /> (for wo►k on honras that wan constructeat jpriori to 1#78 <br /> Phone: (call) -(office) ria r.Z - 7 JP & ..5500 <br /> Mailing Address: 303 4 CI . 5 ZIP: S 0 <br /> Contact Person: b Applicant Is: Cont Homeowner immia one) <br /> Email and/or Fax: <br /> el ge <br /> PROPERTY OWNER INFORMA ON: <br /> Nerve: <br /> Phone(day): A)9- Q4`ar <br /> Address; O 40 14 . City. rn n ZIP; S'S 1 <br /> Email and/or Fax <br /> PROJECT-INFORMATION; Overall project d I sari tion: m ; <br /> Typo of Projea�t; Any earth m ment may 'also <br /> .+,quire <br /> ❑�Ka) CJ Remodel W Fire Damage MCWD ravlOw.&parmits: <br /> Xwroof,asphalt ❑ Repair Storm Damage Mlnnehaha Greek Watershed-Dletrie (MCWD) <br /> ia2m❑Re-roof,ceder ❑ Restoration Water Demes eeph v nrr MN 5 Blvd <br /> Damage t)aepheven�,MW 55391 <br /> ❑Re-roof,other(rpeoi y) ❑ Siding Other,(specify) Phone; 962.471-Woo <br /> ow(s) Fax:.962.471.0882 <br /> WindEstimated Conoructicn valuation of project( cluding land) $ Al 4 M <br /> ,APPLICANT ACKNOWLEDGEMENT: <br /> Agrees to provide all Inf nriallon required or req eaten! by the Building Department; <br /> • Certlfles that the information supplied It true en j correct to the best of hiamer knowledge, The applicant.rempnlzes that they are <br /> solely responsible for aubmift a complete api�hnatlon being Awive that upon failure to do so,the stiff has no sltemetive but to <br /> reject It until It Is Complete; <br /> N Some or at of the information tW..you are adl�vd to provide on this application Is claaslfied by State law as either private or <br /> conildentlal. Private data is It'nfonnetion which'�nZy cannot be given to the public but can buy given to ft.subject of the data. <br /> Confidential data Is tMbmlation vutdch generalire given to wither the.public.or the subject of the date, Our purpose and <br /> Intended use of thee.Imam ation Is to annually te our re=de and records of other governmental agenoles required by low. If <br /> YOU refuse to supoly the 1 rma on the OplicsAM,may not be issued. <br /> Applicant's Signature: 0, Data: <br /> Owner's Signature: per; <br /> Last Updated:031 N013 <br /> 2 a5#ed L6,6PO22L2 T 9 1SWO3 31IHXdd 13rN3SU1 dH WU2*, : I i b T 02 CO '400 <br />