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� <br /> .�� <br /> :� <br /> . City of Orono `.�s <br /> � <br /> � Buildin Permit A lication for Internal Work � <br /> 9 pp Y <br /> (windows, doors, siding, re-roof, etc.) ��`S� � ��� � <br /> � <br /> Mailing Address: Permit number: ����" �G /� � <br /> g,�,�. PO Box 66 '� <br /> � � O Crystal Bay, MN 55323-0066 Date received: a� �',�%/ � <br /> �_,�� _ � . <br /> a �'� �!:�, �, Street Address: Received by: �G'. � <br /> �'.�,t '� �;;,q�,��ti 2750 Kelley Parkway��I IQ 1�� Plan review fee: �� � . �� � <br /> 9kESx0g Orono, MN 55356 � � <br /> c�?��// - �"'G/�3/ `� <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � <br /> � <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: ��'1'(-�`f„-�{ �� � a ��;-� � '� <br /> 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 applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> ►vame: J�N'Dl-�. ���f.�1 . l V\)C,� �� <br /> State License# ()'Z'Z l� Expiration Date: '' �l <br /> Phone: C ' 2 office cell � <br /> Mailing Address: =� Cit : � ZIP: ' � � <br /> Contact Person: Applicant is: tra or / Homeowner �c���ie o�e> �� <br /> s! <br /> Email and/or Fax: � ;� �� " dV� � ; <br /> � <br /> PROPERTY OWNE INFOR TION: � <br /> Name: lt'Ul 4 4 �Ati �, ��� � <br /> Phone (day): 1 <br /> Address: " �,t -- ���' City:l����}� ZIP: S�J�I � <br /> Email and/or Fax � <br /> — n <br /> � <br /> PROJECT INFORMATION: � <br /> Type of Project: Any earth movement may require 'a <br /> MCWD review&permits ry <br /> ❑ Door(s) �Remodel ❑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 /> � Fax: 952-471-0682 =;� <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orp � <br /> Overall Project Description: � (�t �, � G t i <br /> Estimated Construction Valuation of Project(excludi g land) $ Z,� � � <br /> � j— � <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 /> 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 /> 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 refu e to I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: � <br /> I <br /> Last Updated: 05-04-2009 `r:, <br /> i; <br /> t <br />