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� <br /> City of Orono <br /> ' ' Building Permit Application for Internal Wnrk <br /> (windows, doors, siding, re-roof, etc.) <br /> MailingAddress: Permitnumber: O//— `�7 <br /> O�,D,�O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> ���''' Received by: <br /> ,� � .��;-� �, Street Address: <br /> �'�,c, �' ;r �r.�' 2750 Kelley Parkway Plan review fee� <br /> t�kESH�4'� Orono, MN 55356 <br /> Total Fee: � ��, 5� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must ' e submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION• /� j <br /> Job Site Address: � � v�� �`����G� �✓ti�/ �f� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes,a specia!event permit is required with Police Department and City Council approva160 days prior to the eve�nt. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events w�ill not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: f'�'Jj�;,�t'S f <br /> State License# ��(� � � � Expiration Date: �� - �/�- (� <br /> Lead Certification Number: Expiration Date;: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: �ci 3 !-�,,� 7 ��{!L-, (office) (cell) <br /> Mailing Address: S'( S -�r�,.t�,.-� f_ City:r�f>'�e� � �,�.� ZIP: �-c s�' <br /> .S�.� <br /> Contact Person: ' ,��f%� Applicant is: ntrac / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �/t�I c! �'���,�',/l � <br /> Phone (day): <br /> Address: � �: �c Cc..� G•��tr`icl �/� City:�J�'-?C� ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth m�ovement may require <br /> ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review 8�permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Siding ❑ Restoration ❑ Other: (specify) Deeph�aven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Overall Project Description: %��„� c;�f��- �'��-.5;��' � �� c.,�c� `�" _y����y� <br /> Estimated Construction Valuation of Project(excluding land) $ �7�U <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to dc� so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified t>y State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I the information, the a lication ma not be issued. <br /> ApplicanYs Signature: — Date: ���-r� <br /> Last Updated: 03-01-2011 <br />