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�, City of Orono <br /> Buifding Permit Application for tnternal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: d l�''d/ �� <br /> O.¢,D,�.O PO Box 66 <br /> � <br /> Crystal Bay, MN 55323-0066 Date received: i C7 <br /> ,� �`� �, Street Address: Received by: <br /> '�, � Gti�' 2750 Kelley Parkway Plan review fee: <br /> t.�q�Hog*� Orono,MN 55356 <br /> �--- Total Fee: a C�� • �J� <br /> Main: 952-249�1600 Fax: 952-249�616 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. (P�ease print) <br /> GENERAL{NFORMATION: <br /> Job Site Add�ess: 2�--�--5 Sb�1��L��� �, �(,Ci�SI�� ` YYl►'1 `�3�I <br /> Will this be a Parade of Homes, Remodeters Showcase Home or other Display Home? Yes No <br /> lf y�es,a special event permit is requrred with Police DepaRment and City Counci!approval 60 days prror to the event. ShutUe bus service wift be <br /> requi►ed unless applicant demonstrates sufficient on-site part6ng is available. Non pemritted events will not be aUowed. <br /> CONTRACTOR/ ICANT INFORMATION: <br /> Name: �-��-F',� �j�jti�-r� <br /> State License# Z,"�t 1?;Z P�`� Expiration Date: <br /> Phone: �p 12��'3� c_��iL� (c�iee) (cell) <br /> Mailing Address: � � �/e� C : G tP: <br /> Contact Person: �,h-�, Sj���-, Applicant is: ontt / Homeowner �c��o�e� <br /> Email and/ar Fax: �,��-x-��;�y.��. C`�.v 1�(�t-rY�G�,� , Lp►-Y� <br /> PROPERTY OWNER lNFE}s'�3�?:Cs�: <br /> Name: r���C�-� Y1'��IL- <br /> r�nnp r��y� � ' 2`3 <br /> �...,. ,. . <br /> Address: �-2S �v��L��$]C Y�� G�Y��k��Y" ZIP: �3`31 <br /> FmBil�n�/pr Fax �-,�/�-v��l^[Y 1�51� ( C��� <br /> ��t?.fE�T 3N�(3RMATlON: <br /> Type ot Project: Any earth movemeM may reqaire <br /> M f I �cwo���W���� <br /> ! ❑ �oor(s) I ❑F�emociei �water t�amage f <br /> rivilrtrt�ha�ta��eek'v'Vai�rsFi�ti uisufci�iviC'vVD} <br /> ' ❑V:�indo�:,s} �4�pa�r ❑3ta�m Darrage ' t3202 Minnetanka�lvd <br /> �RP;?haven,MN �5�9'! <br /> � ❑Siding � ❑Restoration ❑Qther:(specifyl Phone: 952�71-0590 <br /> Fax: 952-471-0682 <br /> ❑Re-roof ❑Fire Damage www.minnehahacreek.orq <br /> �s•�!�!! P�CjE'Ct DBSCT:�3tl�.^.: <br /> Estimated Constructio��fatuation of Pro;ect(excluding land) � �"j_, '�,� <br /> APPLiCANT ACKNt3WLEDGEMENT: <br /> . Agrees to provide a!!informatian required or requested by the Building Departmerrt; <br /> • Certifies that the information suppiied is t�ue and caRecE ta the best of his/her knowledge. The applicant recagnizes 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 uniit it is complete; <br /> • Some or aii of tfie information that you are asked to provide on this apptication is ciassified 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. Confidentia! data is information which generally cannot be given to sithsr the public or ihs subject of the data. Our <br /> purpose and intended use of this information is to annua�ly update our records and records of other governmental agencies <br /> re u+red b law !f ou refuse to su I the information,the a lication ma not be issued <br /> :a:�ai:�i;�.:.v;�;u.>,-�. � u..,�,. ��I� l �� <br /> _��:'v;:�iczc•�": ET4=ti�2--�=i:�.. <br />