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<br />` s Buildin Permit A lication for Internal Work
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<br /> (windows, doors, siding, re-roof, etc.) �;;
<br /> Mailing Address: �
<br /> � 4v�,� PO Box 66 Permit number: �D�q— DO�
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<br /> Crystal Bay, MN 55323-0066 Date received: G—Z9—D 9 �
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<br />�"� ��a ��� �;�;�. s,�� StreetAddress: Received by:
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<br />� �n ��� 2750 Kelley Parkway Plan review fee:
<br /> "� �t�v ,�� � ��� Orono, MN 55356 � -
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<br />,, ; Total Fee:
<br />�;rY, Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 9�7. � �
<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: �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No
<br /> /f yes, a special event permit rs required with Po/ice Department and City Counci/approva/60 days prior to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wil!not be allowed.
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<br /> a; CONTRACTOR/APPLICANT I FORMATION: p�
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<br />��:: Name: ' ( IC ��,�.. ,t� �,�_� G ;�)
<br />�� State License# 7_Gj 7( Expiratiqn Date: �3� zo 0
<br />�:' Phone: S ZZS office) ��Z C r�'' .��� cell
<br /> Mailing Address: 2�3 Ge.�r S Cit : �,, ZIP: SS o�
<br /> Contact Person: ; Applicant is: ontractor / Homeowner (Circle One)
<br /> Email and/or Fax: U v� c�` a. �G ,Cc; �1 oJ< 6S1 Z..,`�� ��
<br /> PROPERTY OWNER INFORN�1TION:
<br />�`� Name: �nl�n � 5nr�v� '��T`�i�r�(�C�
<br />�"°� Phone (day): U S� 6 �-7 S; �Z `
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<br />�"`' Address: (7(�> .ti �.���„ /2� Cit : C�t)+�9� ZIP:
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<br /> Email and/or Fax -
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<br />�" PROJECT INFORMATION:
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<br /> Type of Project: Any earth movement may require
<br />��" MCWD review&permits
<br />" ' ❑ Door(s) �Remodel ❑Water Damage
<br />�. Minnehaha Creek Watershed District(MCWD)
<br /> ❑ Window(s) ❑ Repair ❑ Storm Damage � 18202 Minnetonka Blvd
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<br /> Deephaven, MN 55391
<br />*� ' ❑ Siding ❑ Restoration
<br />,;,,.: ❑ Other. (specify) Phone: 952-471-0590
<br />�.F; Fax: 952-471-0682
<br />�.: ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq
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<br /> Overall Project Description: h,,,�;,� �� i ,
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<br />�' Estimated Construction Valuation of Pro'ect e ludin land $
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<br />:� APPLICANT ACKNOWLEDGEMENT:
<br />�^" • Agrees to provide all information required or requested by the Building Department;
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<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 alternative ��±
<br />�`�"'� but to reject it until it is complete;
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<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 �
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<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
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<br /> re uired b law. If ou refuse to su I the information, the a lication ma not be issued.
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<br />�`�; Applicant's Signature: � Date: �� � �;� �'� �
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<br /> }; Last Updated: 05-04-2009
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