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1110112016 12:33 GLOWING HEARTH&HOME 1009524926006 P.0051005 <br /> WE ACCEPT MASTERCARD, VISA, AND,DISCOVER <br /> FOR,PERMIT FEES TOTALING LESS THAN $1000 <br /> This Information will:be destroyed after the permit has been oroce.ssed, <br /> • • Under Minnesota:law the information provided on tbis application is gonsidereck poblic and isayallable <br /> to anyone,except for the <br /> The'information regarding your creditscard is privateand will be proVided only to you and to those <br /> people necessary to process your pernent,This Includes city employees who process your payment <br /> and employees of saPPliaablelnienelatinstItLitions..Yotrare not required to titOvide.Yo*Otedit card <br /> inforrpatorrifyog want to pay by andOwr:rrtetiva.HOwever,if you choose to pay twaredlt card you <br /> must provide your credit card information to pay the appropriate fee,„"OriterWise,,YOtir appEOP9Ori Will <br /> not be procesied, <br /> To:Pay,By Warne*I it appears oncard: YNNONINk..4 S‘VI:i <br /> Credit,Card Type of Ctedit:Catd: EfVita o MasterCard so DitcoVir. <br /> • MasterCard <br /> Expiration Date: n- / / W <br /> Visa or ,Ap000nttiumber: 'Ft fr 5v - kilo IS 17 <br /> Discover <br /> Signattire: Date: <br /> piffling Address: \ktrr-61/4ab <br /> qty: State:IfY\IJ Zip Code <br /> Notice: Faxed applications will not be.processed <br /> without'pay:mot by Credit card <br /> • <br /> :Rev:10A/2010 <br />