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<br />�� City of Orono
<br /> . .
<br />�:: Building Permit Application for Internal Work �
<br />� (windows, doors, siding, re-roof, etc.) �
<br />� ;� ti..
<br /> ' Mailing Address: Permit number: ���O— ��J� �
<br /> #�` �0,� PO Box 66
<br />� `:
<br />'�' � k\ Q Crystal Bay, MN 55323-0066 Date received: ��/ /O
<br />��
<br />�,-� �`�,c�., . �
<br /> r.�w� a ��`�'� ��-�+;,, �, �� Street Address: Received by:
<br />�'„', �'� 4 �q� �ti 2750 Kelley Parkway Plan review fee: //
<br /> t`�kEsxot''� Orono, MN 55356 �I T �:�
<br />� �� �� � U
<br />� Total Fee: �j 5�
<br />��f 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 be submitted.
<br />�.:>;. Incomplete applications will be returned. (Please print)
<br />� GENERAL INFORMATION:
<br />�`� Job Site Address: �,-L ; ,��, � �, � �
<br />��,' Will this be a Parade of Homes, Remodelers Showca e Home or other Display Home? ❑ Yes � No
<br />��°; If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be
<br /> r��y� requrred unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br />�. CONTRACTOR/APPLI A JT INFORMATION: ;�
<br />�r: Name: '�-� ��.S�riv�ra✓r �
<br />�� State License# Expiration Date: � Z
<br />�;�� Phone: - �7 -8?ad office cell
<br />�' � Mailing Address: /� y� Cit : �'�, ZIP: �- �
<br /> : Contact Person: �, � Applicant is: ontra to' / Homeowner (Circle One)
<br />�= Email and/or Fax: �
<br />�-�; -� � � y7y- ��oo
<br />�; PROPERTY OWNER INFORMATION: �;
<br /> Name: �h�✓r� �/'���
<br />�� Phone (day): � - _ �-� � _ —
<br /> ' Address: � - ,, � Cit : n-�� � ZIP: �
<br />�'� Email and/or Fax s� �
<br />, >.
<br />�F
<br />' `` PROJECT INFORMATION:
<br />��
<br /> a"Y Type of Project: Any earth movement may require
<br />� MCWD review&permits
<br />��� ❑ Door(s) �Remodel ❑Water Damage
<br />��tn; 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 />�;t �.
<br /> Fax: 952-471-0682 �
<br />� , Re-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> �
<br />�'� O erall Project Description:
<br />�,t; Estimated Construction Valuation of Project(excluding land) $ � /�(`� c�
<br /> k` T�`
<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 recogni2es that they
<br /> - are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative
<br />��_" but to reject it until it is complete;
<br />�y.,
<br />�4�. • 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 />��;,:
<br /> r 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 />,�;
<br /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued. �
<br />��
<br /> s
<br />` Applicant's Signature: Date: � >��a
<br />�v� �� � i�
<br /> � ,j�
<br /> �
<br />�`f Last Updated: 05-04-2009 �
<br /> � �� <� ; x '� � x
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