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� .... .., , , t: <br /> . ���� �,�� � � <br /> > � <br /> , �; , : <br /> `..��, �� � `- ._�. ,, � <br /> , <br /> ��� �-���� City of Orono �� <br />����- �_ , <br />��i � Building Permit Application for Internal Work ' <br /> � <br /> :� <br /> (windows, doors, siding, re-roof, etc.) � <br /> >� <br /> Mailing Address: Permit number: <br /> �,i,�,� PO Box 66 ; <br /> �� � Crystal Bay, MN 55323-0066 Date received: �; <br /> �a �� �e�'S� s, � Street Address: Received by: �`� <br /> �' '��^� �' 2750 Kelle Parkwa 4� <br /> �': �� Y Y Plan review fee: �� <br /> � <br /> �`�gESK�'� 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 all required information must be submitted. ;;� <br /> k Incomplete applications will be returned. (Please print) <br /> �n� GENERAL INFORMATION: ,� <br /> Job Site Address: I y�/S �1i ac�� c-„�c>c�� /��r r' /r./�9���rrC �ic� SS.�9 � � <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 wil!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: SToNF��Z �l� �¢�T�S:��`5 �'�r c - � <br /> State License# g G Zo�v Z 7 79L� Expiration Date: Z���� � <br /> i Phone: 9�5 2� Z/Z�- c�� � % (office) �SZ - Z�'Z-c�/� `� (cell) �� <br /> � Mailing Address: -> • �/.� UX Ci � � �� ZIP: ,s���c��jc- � <br /> Contact Person: Gi.,/� j ,.���y�,.gf Applicant is: Contractor / Homeowner (CircleOne) <br /> Email and/or Fax: C;r u crr <br /> PROPERTY OWNER INFORMATION: <br /> Name: /� i�/�i t- �-�-=-1 t4�.�-� 1��-�t 1=-� ��K�,, d OQiG���i I ,� <br />��.� Phone (daY)� 4.1z - ��1 �- �'// / � �: <br /> Address: ,�S-h� ,,��� �,� Cit � SS � �� � <br />�.. Z.�7`� �i Y�/\/�sv� v�^� ZIP: � <br />�� Email and/or Fax fS�z-- �7f - �//t/ � � . � <br /> r� <br />:�; �:r� <br /> PROJECT INFORMATION: 1�� <br /> Type of Project: Any earth movement may require �-± <br /> MCWD review &permits �' <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <� <br /> sz <br /> t: ' Minnehaha Creek Watershed District(MCWD) s <br /> �. ❑Window(s) �Repair �QS' ❑ Storm Damage 18202 Minnetonka Blvd ^� <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 AE <br /> . � <br /> 't ' Fax: 952-471-0682 r� <br /> � Re-roof .j3 5i— ❑ Fire Damage www.minnehahacreek.orq � <br /> Overall Project Description: �� <br /> �; Estimated Construction Valuation of Project(excluding land) $ j� �� ./ �� <br /> 1- � <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 `b� <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 information, the a lication ma not be issued. � <br />,`�� -- —_----- � <br /> V�' Applicant's Signature: Date: `%.,Z / Z-�� � �� <br /> �ast Updatec 05-0�-200� r <br /> �r _ . <br /> { <br />::C <br />