HomeMy WebLinkAbout1994-006185 - partial tear-off PERIliIIT
� �,�'TY OF ORONO PERMIT TYPE:
2750 Kelley Parkway • P.O. Box 815 ��;;_!��=_F:����{�
Orono, Minnesota 55356-0815 Permit Number: �^;;ti�.,; ;_�,:,
(612) 473-7357 Date Issued: ;:;�_,::� ;:;:,::a;�
SITE ADDRESS:
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REMARKS:
FEE SUMMARY:
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APPL ANT PERMITEE SIGNATURE ISSUED BY:SIGNATURE
� . ' CITY OF ORONO - BQILDING PER�iIT APPI.ICATION
�/ j�� � Date Received:
Total Fee: $ `� -
Date A�nroved: �
Entered Bv: Per_nit� ' � J - __ -
AT•T• INgOR.MATION MIIST BS SUHMITTED IN FIILL BEFORE PLAN REVIEW WZLI� BE Sg��
(See Check-off List Enclosed? __________
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�� gppI,ICANT IS: �circle one) O<<7NER or CONT.�ACTOR
JOB SITE ADDRSSS: Z � S -fG�L �NQC-2 �-�
ZIP: � S ��l I
(work)
��-v c�, �n � -�, PHONE: (hame) � 7��.�/S U
Nr�: OF OWN�R: � C �
�Q - L c, zzP: SS 3 � (
MATI,ING ADDRESS: 2- r � (-4�� /�!L t�� CITY: �('�a�=
��.�� �C� ��,�,C�,� �,��.%
PHoxE: �3 3 _3�z � -
CONTRACTOR: �-
MAT7•ING ADDRESS�
1 ��� �� �:��- ��i, S ��rrr� cs�: f�1�rD� I�iL�� zzP: ; S ��13
STATE I,IC.�.aNSE: 7 �-� J� �
PHONE:
ARCHZTECT/ENGINEER:
C=�,�,: ZIP:
MATZING ADDRESS:
R.EGISTRATION �
NAME:
Accessory Structure Move
�PE pg �ypgg: New Addition Land Alteration
De�o Re.*node?/Alteration Renovate
PROPOSLD WORK (describe in detail) :
STORSES: SQ. FEET OF EBCH ��R=
NO. OF BEDROOMS:
�,�g�� STAT•T,S: ATT. DET.
ESTZMA�L'D CDNSTRIICTIaN VALIIATION (excludinq
land) : S
I hereby apply for a building permit and I acknowledge that the information
above is complete and accurate; that the work will be in conformaCn deW th �he
ordinances and codes of the City and with the State Building e�it; and
understand this is not a permit and work is not to start without a p
that the work will be in accordance with the a�proved pl.an. -
���,�,q ��„,,�,,� DATE: ��
�— �/�- , 5��.
APPZIC�'�NT'S SIG2IATDRE: vyf' /`'`—�-�---
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' � (����' o� ���I�T�
- Post Office Box 66•CrYstal Bay,Minae�ota Sa323•Muaicipal Offices
M!
° On the North Shore of Lake Minnetonka -
� - o s
DATA PRI�� ��S�RY
13.04 , Subd. 2, "Rights of subjects of
with M.S. our request for a permit or
In accordance } require
�ata", we would I.ike to inform you th o f its depar`ments may
license from the CitY o= Or°no or any
yo
u to furnish certain private or conri dential insormation.
vou are notified that:
e information you f urnish censebrequested_ aetermine your
�, Th e,-mit ar li
qualit=cation for the p uire that
refuse to supply data, but refusal may req
2, You may the permi� or license.
the City deny
be snared w�th other local , s�ate or
3 . The information may
to process the permit oi
federai agencies to the extent necessary
license. , ac��o%
or iice*�se reaulres Councis
d. I= your requested pe'-�it ublic.
`o zDprove, some insormation ma_v become p
� . Yo
u have certain rights under M.S_ 13.04 to rev'-ew pr1V�`e
data on yourself. � ; or
Your full name is required to proc=ss
this applica�_on
6 .
per;nit.
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Phone
I understand mY rights as stated above.
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Signatu
BUILD[NG&ZO`rING-473-7357 • ADMINISTRATION&FiNANCE-473-7358
� PUBLIC WORKS -473-7359
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