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<br /> ' \ � ' City of Orono � �
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<br />�. Building Permit Application for Internal Work =
<br /> '� (windows, doors, siding, re-roof, etc.) �k
<br /> ��;
<br />�� Mailing Address: Permit number. 0�0/�•�� � �
<br /> 4v�,� PO Box 66 p- �;
<br /> � Q4;\ Q Crystal Bay, MN 55323-0066 Date received: O p d `�
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<br /> �z, �, ; Street Address: Received by: ,�
<br /> �'.� � �''� �ti�' 2750 Kelley Parkway Plan review fee: �
<br /> L9kESH04'� Orono, MN 55356 ��
<br /> Total Fee: � �4
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �� < `�� F�
<br /> This application form must be completed in full and all required information must be submitted.
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<br /> Incomplete applications will be returned. (P/ease print) ��
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<br /> F� ` GENERAL INFORMATION: G �.G
<br />`�� Job Site Address: /�ys CU�.-,�1
<br />� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No g
<br /> If yes, a specia/event permit is required with Po/ice Department and City Council approva/60 days prior to the event. Shuttfe bus service ill ='
<br />� ;, required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. �
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<br />�1� CONTRACTOR/APP N INFORMATI N: . ��
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<br /> Name: �.�4S�c,.� n�u�B/,^��' z�(�^ n .
<br />` State License# �p� �8�// Expiration Date: ��
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<br /> Phone: E�/�Z-yYi'� _ ��-'1zL� (office) 6/,;2-�1-'(,�-// 'L f (cell) �
<br /> Mailing Address: /' _��/ �Du,,,,,� ,S7' jIJ.W City: Aa,S'c'� ZIP: SS3a.3 �
<br />�F ` Contact Person: TdnrJ �t-{�� , Applicant is: Contractor / Homeowner (Circle One) _
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<br /> Email and/or Fax: _�'G l.,Q��Q � .��o c� �OL. Cr��,
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<br />�{ PROPERTY OWNER I�f ORMATI �
<br />�, Name: /"(��,2 �2AI19� �
<br />��::' Phone (day): b/� -cf9/— S/3fl ��
<br />� , Address: __/��S" �`ou.�Ty ,e� � City: ,Q�✓o ZIP: ��.3j-� �
<br />� � Email and/or Fax �
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<br />�''`: PROJECT INFORMATION: �
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<br />�� Type of Project: Any earth movement may require ��
<br />��: MCWD review&permits fld��
<br />�;; ❑ Door(s) ❑ Remodel ❑Water Damage �
<br />���: Minnehaha Creek Watershed District(MCWD) �-
<br />��; ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br />�T Deephaven, MN 55391 �
<br />�('. ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 �
<br />� Fax: 952-471-0682 �
<br />�4, ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq `
<br />� Overall Project Description: `'
<br />�`#' _ Estimated Construction Valuation of Project(excluding land) $ r'f; Zzp "'` �
<br />��� APPLICANT ACKNOWLEDGEMENT: �
<br /> z� • Agrees to provide all information required or requested by the Building Department; �
<br />��f` • 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 />'� ' but to reject it until it is complete; ��
<br />�,,,�` • Some or all of the information at yo are asked to provide on this application is classified by State law as either private or
<br />;�" confidential. Private data ' mformat' n which enerall cannot be iven to the ublic but can be
<br /> ,� g y g� p given to the subject of the
<br />$`� data. Confidential data ' informati n which generally cannot be given to either the public or the subject of the data. Our
<br />�'°� purpose and intended e of this � formation is to annually update our records and records of other governmental agencies
<br />�>,,$ re uired b law. If ou fuse to s I the information,the a lication ma not be issued.
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<br />�� Applicant's Signature: Date: 9 /cD
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<br /> = ' Last Updated: 05-04-2009
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