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� <br /> � City o Or� o <br /> � � Buiiding Permit Applicatibn for Internal Work <br /> (windows, door�, siding, re-roof, etc.) <br /> Me�r��9,aaaress: ' � ap/D_OU5 <br /> �0.� PO Boz 66, Permit number: <br /> � Q , Crystai Bay, MN 55323-0066 Date received: / l0 �O <br /> , , i <br /> (� a. � Streef Addr�ss: Received by: <br /> ��`� 2750 Kelley Parkway Plan reviewfee: <br /> ���Rog� �' Orono, MN,55356 <br /> -- Total Fee: � �.�(� <br /> Main; 952-249-4600 Fax: ,952-249-4616 wwwci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be retumed. (Please print) <br /> GENERAL INFORMATI N: � ' , <br /> Job Site Address: � �3 �,,r,l i�[ 1 � lv' ��C.h,; . �,{,J o.Sf ��'�1�- <br /> Will this be a Parade of Hames, Remodelers Showcase ome or other Display Home? Yes No" <br /> !f yes,a specia!event permit is iequired wlth Police Department end City Counci/approva!60 days prior to fhe event. ShuttJe bus service wil!be <br /> required unless applicant demonstrates su�cient on-site parldng is available. Non-permiMed evenfs will not be aflowed. <br /> CONTRACTOR!APPLICANT INPORMATION: <br /> Name: S /',-D%d.� P�NJ � N � ' ; <br /> State License# Expiration Date: <br /> Phone: G 12 - `G - ` (affice) , _ (cell) <br /> Mailing Address: 1 3 3� �"� o�rv � n.Q � L r..l City: ��I r e Y V i -ZIP: ._ So a <br /> Contact Person; S A s�i�r .; �Applicant is; Contractor / Homeowner (Clrele One) <br /> Email and/or Fax: S P�:w• ; <br /> PROPERTY OWNER INFORMATION: ' <br /> Name: S A-'[�i�' 0��,4 n� � <br /> Phone(day): — ,,� - 1 <br /> Address: ��3� n��uh -�l CItY+I/��'�fi�C�'1 ll� z�P• nf�G� �C���� <br /> Email andlor Fax <br /> PROJECT INFORMATION: � <br /> Type of Project: ' Any earth movement may require <br /> ❑Door(s) ❑ Remodel ! MCWD review 8 permits <br /> ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Oamage ! 18202 Minnetonka 81vd <br /> Deephaven, MN 55391 <br /> ❑Siding ❑ Restoration ❑ Other:(specify) Phone: 952-471-0590 <br /> ` Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage WA N G'd�r��Yv�K j�� ��`�y � �.minnehahacreek.oro <br /> Overall Project Description: ���,�,('crW� 5�����-F �u ��A�l 05� G�►lX. <br /> Estimated Construction Valuation of P�oject(excluding land) $ <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 c�mplete application being aware that upon failure to do so, the staff has no altemative <br /> but to reject it untEl it is complete; <br /> • Some or all of the information that you are asked to provide an this application is classified by 5tate law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but qn 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, Ou� <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 /> . � .,v -t„i� <br /> ApplicanYs Signature: � �.� � ' Date: <br /> � <br /> ; <br /> LaslUpdated: 05-04-2009 �, <br /> i <br /> T 'd S9SbEZT , SbEZi dGb ��O Oi ZO i�C <br />