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4'4-
<br /> City ��f Orono
<br /> Building P = rm t App ration for Internal Work
<br /> (win;® owe, door- siding, t�e-roof, etc:)
<br /> M=ling Address Permit number: -
<br /> '�V- PO Bqx 66 ,
<br /> t Crystal Bay,MN -:423-0066 Date received:
<br /> .n y' a. St et Addnss Reined by..
<br /> 'i pa ooh 2750 Kelley Pa. 'y
<br /> plan�eviewfee � -
<br /> .° o � .- Orono,Mtst 66366
<br /> ` Total Fee
<br /> Main: 952 249-4600 F- : 952-249.46'16, , www.ci.orono,mn.us.
<br /> This application form mus I be completed in II and ell require ed information must be submitted.
<br /> Incomp 1.to applications:f'ill be returned. (Please-print) '
<br /> GENERAL INFORMATION:
<br /> .Job Site Address: �$`a5 S eta 1l C 1 lit'►7 O
<br /> Ilhls be.a Parade of Homes, Re •deters Sliowc a H©me dr other Display"Name? 0-Yes
<br /> If yes,a special event permit is required with •lice De No
<br /> pcient 0t dt►s €ity council approval 60 flays p►ior:t the event SfiuEge hu services' --,., ;
<br /> required unless applicant demons -fes'sufficient on s lacing is available N©n pertttitted events will not/14311W o
<br /> CONT '2A.CTOR/APPLICANT INFOR TION:
<br /> Name: Ivas�wap « Nsiu�c to SLC
<br /> State License# 2abtp%S31 'L . r Expiration D e
<br /> Phone. �.. 'V.3- '1 t:'I : =t 4 d it Ice) ( h
<br /> Mailiing.Address: i BBBt 1a ah,,-, i, �.; , :
<br /> Contact=fie son: �•' � IP 5 w
<br /> r �1a © Applicant is Dutra -,o /, , FHomeowner .> lci/tot
<br /> Email and/or Fax: s
<br /> PROPERTY OWNER.INFORMATION:
<br /> Name' L ,fl1P,sz r►rsa 5
<br /> Phone°(day): gS'Z ypc �.,4,
<br /> Addre iii a\d ays}�..t 13 tis 'D � 0 lP ►�S
<br /> Email end Fax
<br /> T. ,� F `. {�
<br /> ' !R�. T 1NI=;6k1' I ATION: i. .. p r T.
<br /> Type off j ect q ,-.„,„4,e �rt
<br /> '21--1,1-'9°114), I Remodel Q Water D:r
<br /> 9 llinrnehali�af e' V ate. i'Drg ct(MC1 /
<br /> , WIq�(s� ��epair Irl Btd►�ii`� i• �e � =,---,e-'-, �� (,� � �� rt �•
<br /> &ifa � N�5 1f ,
<br /> o
<br /> siding 0--,R esto tion
<br /> ❑Other w, ofy h"bnet; 2- 1r0
<br /> Its-roof_ I Fire Damage ` 5 7.1 t
<br /> ex it �—"ha�ld t�# - ,i,
<br /> Y roject5Descriptlon. t
<br /> "timated Constructi©n Valuation of P •jecf(excluding
<br /> APPLICANT/ CF l
<br /> {' O4EMEN.T
<br /> • Agrees to provide all in ormation requi, . or requested by,;�eBuilding Department,
<br /> • Certifies the information supplied s true and correct'. the best df his/her knowledge The;*applica re nines that. ey r ,
<br /> are�solely that th infer for submitting :-,complete epplirati.e being aware`athat upon failure`to do<so,thus ff h s neap.a title
<br /> but to refect it until itis complete;
<br /> Some or •all of the information{that yo are asked to pro •e on this application is classified by$ , - ' 'State jaw,esti either, iv or
<br /> confidential Private data is informati.n which generally' .nnot be given to the public but can,:'be Ygiv n to the subject the
<br /> data. Confidential data is nformatio ,which generally riot be given' °.ta either the public or the subject of`the d'a`fo u
<br /> purpose and,intended use of this info matron is to annu-., update our records and records of other governmental agencies;,,
<br /> required by law. If you refuse to suppl,,the information,th =pplication may not be issued.
<br /> Applicant's Signature: „ 1M ! Date: J( /3o/O
<br /> I
<br /> Last Updated: 05-04-2009
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