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<br />��- , ' City of Orono -�`�: ��
<br /> �
<br /> �. �- �
<br />� 6
<br />�: Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.) '
<br />_ ci:
<br /> Mailing Address: ��
<br /> �,0,� PO Box 66 Permit number. '�
<br /> �
<br /> � 0
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> .� �p �'�E-�a;� a,� Street Address: ��� Received by: �
<br /> x'� { "� :A? Gti 2750 Kelley Parkway Plan review fee:
<br /> t`�gEsHo�`'� Orono, MN 55356 �
<br /> � Total Fee: i"
<br />''"' Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �
<br /> �t 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 /> ��
<br />��= Job Site Address: 'G�������; � ����._ ��--��� �
<br /> r Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes [�No ;_
<br /> If yes, a special event permit is�equired with Police Department and City Council approval 60 days prior to the event. Shutt/e bus service will be ���
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. �
<br /> �s
<br />� ` CONTRACTOR/APPLICANT INFORMATION: �'
<br /> ' Name: ;c a. � � ' 4�v ad/ �
<br /> � State License# L� Ex iration Date: � /r��'G `
<br /> �_ ��S�?�a P� c.�t • e� t�
<br />�, Phone: � — � office cell �
<br />�, Mailing Address: , � Cit : r'ps' ZIP:�� ' � �
<br /> �,
<br />�` Contact Person: ��,,�� �,�,/�.,1s�e n Applicant is: ontracto / Homeowner (CircleOne) ��
<br />�<= Email and/or Fax:
<br />�- `�
<br />�:; �;
<br />�,'` PROPERTY OWNER INFORMATION: �
<br />�;_ Name: �c�� (l.����2f�k;
<br /> Phone (day): �
<br /> Address: `n Cit : �
<br /> 5 a2� (�. � 7...�c.; � ZIP: ;�S-3�l
<br /> Email and/or Fax �� �
<br />�: �:,
<br />;�=�; �
<br /> �
<br />� = PROJECT INFORMATION: �
<br />_;,�� �
<br />�` Type of Project: Any earth movement may require '
<br />" '- MCWD review 8�permits �
<br />�� ❑ Door(s) ❑ Remodel ❑Water Damage �
<br /> �
<br />��� Minnehaha Creek Watershed District(MCWD) �
<br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> ;�;
<br />�, Deephaven, MN 55391
<br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br />$ :
<br /> k � Re-roof Fax: 952-471-0682
<br />�,� ❑ Fire Damage www.minnehahacreek.orq
<br />��� Overall Project Description: ,i
<br /> ti� Estimated Construction Valuation of Project(excluding land) $ ��j� �
<br /> � �
<br />,,�.; APPLICANT ACKNOWLEDGEMENT: �`
<br /> �
<br />��� • Agrees to provide all information required or requested by the Building Department; '�
<br />�� ��
<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 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 /> F; confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the �t
<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 govemmental agencies ��
<br />� ` re uired b law. If ou refuse to su I the information,the a lication ma not be issued. ��
<br />�:y; �
<br /> /
<br /> k `-
<br /> ApplicanYs Signature: ��' .� �ate: � �� "��
<br /> �
<br />�= Last Updated: 05-04-2009
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