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<br /> City of Orono �
<br /> �
<br />� � Building Permit Application for Internal Work �F,
<br />��t (windows, doors, siding, re-roof, etc.) #;'
<br /> �
<br />�� Mailrng Address: Permit number: �
<br /> ^ ' �v�,� PO Box 66 �
<br /> �' Crystal Bay, MN 55323-0066 Date received:
<br />� � �
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<br /> 1
<br />��� !� ��� � �- Received b �
<br />� ; ��� �������;��!,, �, Street Address: Y� �
<br />�� �' p� � 2750 Kelle Parkwa ""�"�� ��
<br /> �� , � � Y Y Plan review fee: �.
<br />��� �'kESH�'� Orono, MN 55356 �,
<br /> �
<br /> Total Fee: �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 4;
<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 /> �, y'J �
<br />�;' Job Site Address: / / � `5 q(/���j jt/� j��, ��
<br /> '' Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No �;
<br /> � /f yes,a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle 6us service wi/l be �
<br /> _ required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ;�
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<br />�� CONTRACTOR/APPLICANT WFORMATION: y;
<br /> Name: ��:
<br />�a State License# Expiration Date: �
<br /> ; Phone: (office) (cell) �'
<br /> Mailing Address: Cit : �
<br />�� Contact Person: Applicant is: Contractor Homeowner ircle One) e
<br /> t� Email and/or Fax:
<br />�.
<br /> rt..:- �
<br /> F��'
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<br />�-.�' PROPERTY OWNER INFORMATION: f
<br />}� Name: ft/U�h„��� �j¢��i�!/j�- �
<br />�7 � Phone (day): q`� c,/ �
<br />��� Address: �������
<br /> city:�iv� ziP: 5�3�1 �
<br /> � Email and/or Fax �
<br /> � �
<br /> ; PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require �
<br /> �' MCWD review& permits �
<br /> �'� �Door(s) ❑ Remodel
<br /> ❑Water Damage
<br /> �N°: Minnehaha Creek Watershed District(MCWD)
<br /> �3 ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> �,
<br /> : Deephaven, MN 55391
<br /> '� ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br /> �:
<br /> �:, Fax: 952-471-0682 °�
<br /> ,.: ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> K� Overall Project Description: F�
<br /> E Estimated Construction Valuation of Project(excluding land) $ � ��
<br /> . �
<br /> APPLICANT ACKNOWLEDGEMENT: �
<br /> ffi • 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 /> � �,.
<br /> < are solely responsible for submitting a compfete application being aware that upon failure to do so, the staff has no alternative �
<br /> ��
<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 taw as either private or �
<br /> h ` confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the 3�
<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 uire d b law. I f ou re fuse to s I t he in formatio t he a lication ma not be issued. �
<br /> h � `O �
<br /> Arrlicant's Signature: �ate: � '4 '�
<br /> s-.: `�
<br />� Last Updated: 05-04-2009 �
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