HomeMy WebLinkAbout1992-004783 - land alteration --. —-�---.
PERMIT
f��Y OF ORONO PERMIT TYPE: ��_��� ��r, tk�r��
� 1335 Brown Rd. South • P.O. Box 66 Permit Number: t�i,�.;,�,. , �; .�r- .
Crystal Bay, Minnesota 55323 Date Issued: �� `����
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(612) 473-7357
SITE ADDRESS:
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FEE SUMMARY:
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PLICANT PE ITEE SIGNATURE ISSUED BY:SIGNATURE
� j CITY OF ORONO - BUILDING PERMIT APPLICATION
Total Fee: $ Date Received:
�, Date Approved:
Entered By: �-, Permit n: Z�� � �
ALL INFORMATION MIIST B$ SIIBMITTED IN FIILL BEFORE PLAN REVIEW WILL BB STARTED
(See Check-off List Encl.osed)
-------------------------------------
THE APPLIGANT IS: ( circle ane) O��1NER or CONTRACTOR
JOB SITE ADDRSSS: h` � � ;<vr,� /��h' � -- ZIP: j i 3r 6
(work)
N� OF OWNER: ,�i ���-c i c/ J Y��r�t S �li� PHONE: (home)�7� J>%�°_
MAILING ADDRESS: �� .�, �i� 7` �,� CITY:/.,y�, �j�/� _ ZIP: 'j ,� 3� �
CONTRACTOR: � � 1 - PH��
MAILING ADDRESS: CITY: ZIP: �
STATE LICENSE: #
ARCHITECT/ENGINEER: PHONE: ..
MAILING ADDRESS: CITY: ZIP:
NAME: REGIS�'R�TION � _
TYPE OF WORR: New Addition Accessory Structure riove�_W__
Demo Remodel/Alteration Renovate Land Alteration�
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PROPOSED WORR (describe in detail) : il��„�� c- �'• r � /�ic�-iy� � � ���
_ .� �, � _ �' �� �r�// /�-v c ;.. �'c�,�� o-- �-� c'�. .f
STORIES: SQ. FEET OF EACH FLOOR:
NO. OF BEDROOMS: G�GE STALLS: ATT. DET.
ESTIMATED CONSTRIICTION VALIIATION (ezcluding landl : $
I hereby apply for a building permit and I acknowledge that the information
abvve is complete and accurate; that the work will be in conformance with the
ordinances and codes of the C��-�---and with the State Building Code; tha� I
understand this is not a permit and wo�c is not to start without a permit; and
that the work will be in accox'dance with�he approved plan.
, __� DATE: // Z�
APPLICANT'S SIGNATURE: �
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��� Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices
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• _ ��`%� ` On the North Shore of Lake Minnetonka
DATA PRNACY ADVISORY
In accordance with M.S. 13.04 , Subd. 2 , "Rights of subjects of
data", we would like to inform you that your request for a permit or
3.icense from the City of Orono or any of its departments may require
you to furnish certain private or confidential information.
You are notified that:
l. The information you furnish will be used to determine your
qual.ification for the permit or license requested.
2. You may refuse to supply data, but refusal may require that
the City deny the permit or license.
3. The information may be shared with other local , s�ate or
federal agencies to the extent necessary to process the permit or
3.icense.
4. If your requested permit or Iicense requires Councii ac��or.
to approve, some information may become pub3ic.
5. You have certain rights under M.S. 13.04 to review private
data on yourself.
6. Your full name is required to process this application or
permit.
TI A�c %c� � �.ti Gc S���t
First Middle Last
� �� �: �iitir � (��2� ` G_-
Address
C c /v, .� S"�s._ G
City - State Zip
���- ; 3 �L -
�r. y
Phone
I understand my rights as stated above.
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Si ature "--- �
BUILDING&ZONlNG—473-7357 • ADMINISTRATIOIY& FIIYANCE--i73-7358 • PUBLIC WORKS —473-7359
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