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t k � _ . . ,`�`''gF�'_:.' ,��, �, .'�e'��"' _ a:;� i :� <br /> � - � .� 3 �� � <br />� a � - <br /> n_ . . - . . - . . . .. �' �, �� ! ti."` �st � �` �'� <br />{�� City of Orono `� �� �`� <br /> � �:�: <br /> �; . � Building Permit Application for Internal Work � '��'�� ���� <br /> a <br />�,` (windows, doors, siding, re-roof, etc.) � <br />�= � Mailing Address� <br /> �.. <br />� �0�� Permit number. <br /> � PO Box 66 <br /> Q O�, Crystal Bay, MN 55323-0066 Date received: � <br /> �a ���' s.;y a i Street Address: f Received by: �; <br /> �� ��'�� � 2750 Kelle Parkwa � <br /> '�`' ���� o � y y Plan review fee: <br /> t'�.gESHo�`'� 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 /> Incomplete applications will be returned. (Please print) � <br /> GENERAL INFORMATION: <br /> Job Site Address: , � � S � � �, � � <br /> 1 C�� - �i�.-�l� �- � <br /> ti' Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No � <br /> If 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 appficant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. r� <br />+ � �sb <br /> CONTRACTOR/APPLICANT�IFORMATION: � <br /> 1s,' � <br /> Name: �u•��,, I�dd�-r n5 <br /> State License# 2os 8-66E� ' Expiration Date: 3 �D <br />�;� Phone: 9�1 �37 "3u�s� (office) (cell) a� <br /> . Mailing Address: `1SJ�3 Sy�� w�;��0� Cit : � ZIP� S c� � <br />,�, Contact Person: �� u� ,�se,�, Applicant is: ontracto_,C., / Homeowner (Circle One) <br /> Email and/or Fax: � <br />�.' �, <br /> � <br /> , PROPERTY OWNER INFORMATION: � <br />�� Name: 7c�,�.� ���s�2>--� <br />,`; Phone (day): �G,� (�v 2 tv/ � <br />-:�< Address: 2oS�� Sh��2 „-� O/ Cit : G✓�,7 ZIP: <br /> r. <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 I ❑Water Damage �� <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 � <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 � <br /> Re-roof Fax: 952-471-0682 <br /> ❑ Fire Damage www.minnehahacreek.orq � <br /> j Overall Project Description: �� �� y� <br /> � Estimated Construction Valuation of Project(excluding land) $ �7 ���� � <br />� . <br />�� APPLICANT ACKNOWLEDGEMENT: �� <br />��:, � <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 /> p. 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 /> A,,.,; 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 /> r���-� ti <br />� ' _-____.��._ `�`� <br /> ApplicanYs Signature: Date: ?(�j� � <br /> �� <br /> � <br />�� Last Updated: 05-04-2009 � <br /> � "� �� <br /> .__ , ,. , _.� � ���.r � . .,�� � '_�_ <br />