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<br /> City of Orono � � � � � � � � � � #���� �
<br /> Buildin Permit A lication for Internal Work �
<br /> 9 pp
<br /> (windows, doors, siding, re-roof, etc.)
<br /> MailingAddress: Permitnumber: lj �— OoZ
<br /> �.,0,� PO Box 66 ,t� �
<br /> 0 , Q Crystal Bay, MN 55323-0066 Date received: / /s ;:�
<br />•' I ��,��,. • �
<br /> a � � �-!� a Street Address: Received by:
<br /> � %r '6^�,c•9 �'
<br /> � � 2750 Kelley Parkway �
<br /> ��` �G Orono, MN 55356 Plan review fee:
<br /> kESH04'
<br /> Total Fee: � / �� 7/ �',
<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. (P/ease print)
<br /> GENERAL INFORMATION: S} '
<br /> Job Site Address: l�j�� h�' ��, 1��,�- ��� �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes .-'�1�0
<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 /> Name: G�p.✓��,✓, (� .
<br /> State License# 17 q'b Expiration Date:
<br /> Phone: —J �0 (office —Z $-v
<br /> � cel I
<br /> Mailing Address: Cit : ,�, ZIP: �=�
<br /> Contact Person: Applicant is: ontract / H meowner (Circle One)
<br /> Email and/or Fax: . �
<br /> hx.; PROPERTY OWNER INFORM TION: �
<br /> Name: o✓t 5L� , � t� ,
<br />�;:� Phone (day): Z � 3 Z _
<br />� Address: p Cit : y d , ZIP: � S�
<br /> Email and/or Fax
<br /> �
<br /> ���
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br />�` MCWD review 8� permits
<br /> ❑ Door(s) ❑ Remodel �Water Damage
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑Window(s) �epair ❑ Storm Damage 18202 Minnetonka Blvd
<br />�F- 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 /> Overall Project Description: � � �- � ' � S�, �
<br /> Estimated Construction Valuati n of Project(excluding land) $ 7� 9 7�a �
<br /> j-
<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 complete application being aware that upon failure to do so, the staff has no alternative F
<br /> but to reject it until it is complete;
<br />:,:
<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 annually update our records and records of other governmental agencies
<br /> re uired b law. If ou refuse to su I the inf m tio ,the a lication ma not be issued.
<br /> ��' ' i
<br /> �' � Ku� I�' �
<br /> A IicanYs Si nature: �� u�
<br /> PP 9 �.�Uti Date: ��7
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<br />�1 Last Updated: 05-04-2009 ��
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