HomeMy WebLinkAbout1992-004566 - residing � I'ERMIT
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1335 Brown Rd. South • P.O. Box 66 PERMIT TYPE: �;�a��������
Permit Number: t ai_f4�F.�.
Crystal Bay, Minnesota 55323 Date Issued:
(612) 473-7357 ��:y/17 f��'-
SITE ADDRESS:
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REMARKS:
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FEE SUMMARY: ��'�iJ1�}�}�}�}� #
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CONTRACTOR: OWNER: — AF�F�l i.c ant. —
i�HL�i�!� QAN
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APPLICANT/PERMITEE SIGNATURE ISSUED BY:SIGNATURE ,iCt'��C-°P"�
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` CITY OF ORC:iO - BUILDING FERl''41T APPLICATION
Total Fee: $ �/ '3. �� Date Received:
Date A�nro�ed :
�ntered By: ,.l'�i/ PermitY- �.�(�, C�
AT•T• INFORMATION MIIST BE SIIBMITTED IN FIILL BEFORE PLAN R.EVIL�1 WII.L B$ STARTED
(See Check-aff List EncZosed)
----------------------------------------------
THE APPI�ICANT ISs (circle one) O��ER or CONTRACTOR
JOB SITE ADDR$SS: 3�1(LU 1���� `���G1c. �� ZIP: )JJ(�%`� -
� � (work) �1�� -?y��
N�ME OF OWNER-_ 1)?�'l Oh�z�l . - PHONE: (home) `� 7 y-" �`j�o�
MAII�ING �D�ss: �3��� )�oc�, �1�c���. cl�: M�� zIP: � 5�.3�y
CONTRACTCR: � I� - p$���
1�iAILING ADDRESS: CITY: ZIP:
STATE LICENSE: '�
ARCHITECT/ENGINEER: Pg��'
:KAIZING ADDRESS: CITYs ZIP:
NAME: REGISTRATION T
TYPE OF WORR: New Addition Accessory Structure Niove
Demo Remodel/Alteration�_ Renovate Land Alteration
PROPOSED WORR (describe in detail) : � ��� h G��
M���� \
STORIESs ��°� SQ. FEET OF EACH FLOOR:
NO. OF BEDROOMS:� GARAGE STALI�S: ATT. DET.�_
ESTIMATED CONSTRIICTION VALIIATION (ezcluding Iand) : $ ���(�;� C�,�'
I hereby apply for a building permit and I acknowledge that the information
above is complete and accurate; that the work will be in conformance with the
ordinances and codes of the City and with the State Buil.ding Code; that I
snderstand this is not a permit and work is not to start without a permit; and
�hat the work will. be in accordance with the approved plan. •
I \ �`l DATE: t-I]"�c�
APPZICANT'S SIGNATURE: �e 1�/W ��fi����� �
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Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices
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s � s • On the North Shore of Lake Minnetonka
DATA PRIVACY 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
license from the City of Orono or any of its departments may require
you to furnish certain private or confidential information.
You are notified that:
1. The information yvu furnish will be used to determine your
qualification for the permit or Iicense 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 snared with other loca 1 , s�ate or
federal agencies to the extent necessary to process the permit or
Iicense.
4. If your requested permit or Iicense requires Counci3 ac�ion
to approve, some information may become public.
5. You have certain rights under M.S. 13.04 to review pri��ate
data on yourself.
6. Your full name is required to process this application or
permit.
��� lz�na.� �h\�n�
First Middle Last
3�t�c� ,�,�nc-� �ha�-�,
Address
rn���,� �n� 5�53(�4
City State Zip
�?1 - 7y��
Phone
I understand my rights as stated above.
o.�.�
Si nature
BUILDINC&ZONI�G-473-7357 • AD�i1NISTRATION&FINANCE-473-73_3 • PUBLIC WORKS -473-7359
ASSESSING