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��CEIVED <br /> n - �` �_ f� ci�09 <br /> � .,. <br /> City of Orono CITYOFORONO <br /> Building Permit Application <br /> Mailing Address: Permit number: � ���d�J l�g <br /> �j,�,�. PO Box 66 <br /> 0 a\ O Crystal Bay, MN 55323-0066 Date received: �� - <br /> � `'�` Received by: a 1 <br /> a � �' `i� �, Streef Address: r1 <br /> '$`�, ° �ti 2750 Kelley Parkway Plan review fee: 7 �'tJ � � ���" <br /> L`9kEsx�g'� Orono, MN 55356 <br /> -- Total Fee: ' �, <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � �O� ' 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 AddPess: Holiday Stationstore#3546-2420 Shadywood Drive, Navarre, Mn <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑✓ No <br /> lf 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 /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Holiday Stationstores, Inc. <br /> State License# Expiration Date: <br /> Phone: (952)830-8884 (office) (612)581-3083 (cell) <br /> Mailing Address: 4567 American Blvd.West City: Bloominqton ZIP: 55437 <br /> Contact Person: Joel Geil Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: joel.geil�holidaycompanies.com <br /> PROPERTY OWNER INFORMATION: <br /> Name: John O'Sullivan <br /> Phone (day): (612)366-0163 <br /> Address: City: ZIP: <br /> Email and/or Fax iohnosCa�tcinternet.net <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 8 Restoration ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> 8 Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall ProjeCt DesCription: Install new checkout counters and food area counters. Install oak wood package <br /> Estimated Construction Valuation of Project(excluding land) $ 20,000.00 <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 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 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 inforrnation is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to supply the information,the application may not be issued. <br /> Applicant's Signature: ,,,// +7 _,�� Date: `���01 <br /> Reset Form <br />