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�;_ �^,c� az �gp°�p"�' W".� .`.,^w�*r- � �--x .� '� �y,r�c€� <br /> �' <br /> �'� � , A� �: } r7.. �� �4;'���' ���. <br /> �1 . Y . £iN+', <br /> / <br />��� . City of Orono � <br /> � <br />`��` ' Building Permit Application for Internal Work �� <br /> � (windows, doors, siding, re-roof, etc.) <br />�� <br /> � Mailing Address: <br /> �� �0,����, PO Box 66 Permit number: <br />, � /Q ��. Crystal Bay, MN 55323-0066 Date received: <br /> � � �,:. 1_ �i� � <br /> � <br /> Received b �� <br /> �� a t`�'� •.�_;` s,'! Street Address: Y� <br /> 3� ��� ''"� ���,i 2750 Kelley Parkway Plan review fee: <br />��; �`�kESHo�`� Orono, MN 55356 � <br /> Total Fee: � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ��^� <br />' � This application form must be completed in full and alf required information must be submitted. <br />,�.' Incomplete applications will be returned. (Please print) <br /> - GENERAL INFORMATION: _ <br />}�� Job Site Address: �- 35D - S�l�tC�D�vUa �•GD � ,j�j 3S <br />�.}. Will this be a Parade of Homes, Remodelers Showcase Home or other isplay ome? ❑ Yes �,No <br />� lf yes, a specia/event permit is required with Police Departmenf and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> r", required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br />�x CONTRACTOR/APPLICANT INFO MATION: <br />� � Name: � � O l/C ��f <br /> b� <br /> State License# Expiration Date: p :�-> <br /> �u Phone: - _ � office (cell) <br />� Mailing Address: � ' Cit : �/ ZIP: / _ <br />��; Contact Person: G Applicant is: Contra or / Homeowner (CircleOne) <br />��'' Email and/or Fax: <br />�$. <br />��; PROPERTY OWNER INFORMATION: � <br />� : <br />��' Name: YI - � G C <br />� Phone (day): �� , <br />�;.' Address: �Sf� � Q U/,r��1�i pQ� City: (��?Oj ����� ZIP: S�3�� <br />��, Email and/or Fax �—� <br />„�< <br />�:' PROJECT INFORMATION: <br /> q_, <br /> Type of Project: � Any earth movement may require <br /> i MCWD review&permits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> �: ❑ Re-roof Fax: 952-471-0682 <br /> , ❑ Fire Damage www.minnehahacreek.orq <br />��' Overall Project Description: �Q � <br />��` Estimated Construction Valuation of Project(excluding land) $r <br />,.;<t: <br />, �: APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; � <br />':� <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 do so, the staff has no altemative <br /> but to reject it until it is complete; <br />';Ys,t <br /> � • Some or all of the information that you are asked to provide on this application is classified by 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 /> f;,�:v 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 />��:,'; <br /> ��� L�� � �-`f' �0 0 <br />«ru; ApplicanYs Signature: Date: <br />�� Last Updated: 05-04-2009 <br /> c�:-� x t �; . � �. �� 5,�:'e; ��u�'�-e� i ,� . a „ <br /> . . r <br /> � <br /> i f � Y � �r <br /> =aj __._ . �.'Si f.��.=.6N'�8Z���sl,v...�Ib+`�e'i..s .aL�.�.�}.c �...r�a���_A��� �,��v�'k�a tu.a.3.rYra�.'fc ua#'B <br />