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��-� � � � �� g <br /> , .� � <br /> � .,� � � <br /> s > � <br /> City of Orono � � °�. y s = ��� � <br /> �.� <br /> . � # <br /> . Building Permit Application for Internal Work � ' °` <br /> (windows, doors, siding, re-roof, etc.) � <br /> � <br /> Mailing Address: Permit number. �' <br /> 'Qv�,�. PO Box 66 <br /> Q �\ O Crystal Bay, MN 55323-0066 Date received: <br /> �� � <br /> ,� �� ���-���. �, Street Address: Received by: <br /> �'�,c,� 6" �,ti�' 2750 Kelley Parkway Plan review fee: <br /> `��.ESHo�`'� Orono, MN 55356 � <br /> Total Fee: � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ;;; <br /> ` f' <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 /> �: �:.�. <br /> Job Site Address: �yc>j ��G�,,��� �� � .- <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No -� <br /> lf 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/APPLIGANT INFORMATION: < <br /> Name: ���5�-�Sa.� �2e�v�.���U�, r1- �X�a2S ���� i <br /> State License# � 03���� Expiration Date: '; �/ �� <br /> Phone: � // office cell <br /> '�' Mailing Address: /73 c �� .f ,v:.� Cit : �,�h5��i ZIP: �-1�� � <br /> Contact Person: ,�,, �. 5'��,;zG�,- Applicant is: Contractor / Homeowner (CircleOne) "� <br /> Email and/or Fax: <br /> k+Y <br /> PROPERTY OWNER INFORMATION: <br /> _ Name: J'�h n 4' �c,����, C d�� ��fe�a u � <br /> .� <br /> Phone (daY)� (>>,� 96� i�.3� �' <br /> � <br /> Address: �z�a5- � �y �� City: �/��,�-1�. ZIP: ;; <br /> Email and/or Fax ; <br /> �: <br />�Y: PROJECT INFORMATION: �f <br />� ` Type of Project: Any earth movement may require �; <br /> MCWD review&permits � <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br />��:; Minnehaha Creek Watershed District(MCWD) Y <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.orq � <br />�'re�� Overatl Project Description: �°� <br /> Estimated Construction Valuation of Project(excluding land) $ � �.�.;Z� <br />� °�---�--�— <br /> ' APPLICANT ACKNOWLEDGEMENT: �j-�,-��� �f-�-1� ' <br />, � <br /> • Agrees to provide all information required or requested by the Building DepartmenY, I �' <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 /> �i 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 the informa ' n, the a lication ma not be issued. °�,� <br />�' , <br /> ^ ApplicanYs Signature: `1 �C� Date: % �'-/v <br />�:: <br /> k:' <br /> z:, <br /> ' Last Updated: 05-04-2009 <br /> �; �.. � <br /> . . .., .P-: ,...:..� , �.�._ `` `: <br />