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� �- � City of Orono <br /> Building Permi# Application for Internai Work <br /> (windows, doors, siding, re-roof, etc.) <br /> �•�-� Mad�Pg�Bd�d�ss. Permit number: o2�O�I- OD,30 � <br /> OY '`Y� Crystal Bay, MN 55323-0066 Date received: �P����� <br /> Received b � <br /> a G� �, Street Address: y� <br /> '�, • Gtiti 2750 Kelley Parkway Plan review fee: ,-- <br /> �g�xog*� Orono,MN 55356 <br /> -_� Total Fee: �� / �� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono mn us / �,c_. <br /> This application form must be completed in full and all required information must be submitted. �}-,-�� <br /> Incomplete applications will be returned. (Please print) C� ��_ <br /> GENERAL INFORMATION: � <br /> JobSiteAddress: ���[;� �;j-lF�'1�`� �,;�,�v�(� jc"_ ;.���(��r�l�� .l���ti/ � `��j`i � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display ome? 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 wrll be <br /> required unless applicant demonstrates sufficient on-sife parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �' - `��LL� I��C.r� C�vf" � ' ��.n-!l �`� . /�L <br /> State License# ''�•��� � �I Expiration Date: :� -� � - /��� <br /> Phone: (��%—�i)'� - ,���, �;% (office) ��"���#� (cell) <br /> Mailing Address: j�h'� L;�- ,'r,!-,,:�=, _l` /�/=,.;,= City:�":�";= ;��.�-iv a ZIP: �;--=<�-- <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: ��j�_Y�-S C�fl L � ,�c n fi��vv^ G��t .�� T <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��.�f��'},� � ��,'��{�a`i,r-!�= ��l��� <br /> Phone(day): �--:, - �i�1 - ���1�� . <br /> Address: ��__i�r ;r?n--����� a:'�.:;� I:�� City: ^�:;�,� ZIP: .���:-=} 1 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <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 <br /> Deephaven, MN 55391 <br /> ❑Siding ❑ Restoration ❑Other. (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Re-roof ❑ Fire Damage www minnehahacreek.orq <br /> Overall Project Description: j�� �,����,�� �:-�H-T('G���M <br /> Estimated Construction Valuation of Project(excluding land) $ �, C.-Y�� , �(; <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 do so, the staff has no altemative <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 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 /> 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�nformation,the a lication ma not be issued. <br /> /� C _ �C <br /> ApplicanYs Si�nature: Date: (Si`� � � <br /> Last Updated: 05-04-2009 <br />