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<br /> �; a1� � City of Orono := ��� ���� �� �
<br /> ���:
<br /> Building Permit Application for Internal Work � �{� ��
<br /> (windows, doors, siding, re-roof, etc.) �=
<br /> ��
<br /> Mailing Address: Permit number: �d� ��� �'
<br /> PO Box 66 �
<br /> ��Q� ��� Crystal Bay, MN 55323-0066 Date received: ��� � �
<br /> I•� �`�'i���_,mm. s,�� Sfreet Address: Received by:
<br /> �
<br /> ��n %. °�� ��� 2750 Kelley Parkway Plan revie fee: '�
<br /> L9kESK�g�'j Orono, MN 55356 �
<br /> � / 7g , C� �
<br /> -� Total Fe � � �
<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) f`:;
<br /> � ;
<br /> GENERAL INFORMATION: �
<br />�= Job Site Address: � �U��� �j ;�
<br />�,� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes •, No
<br /> lf yes, a specia!event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service wil/be �
<br />` �' requrred unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed �°
<br /> i
<br />�; CONTRACTOR/AP LICANT INFORMATION: �;
<br />� ` Name: R�.A� �S�«��nsc�ti �9nS�� ��'C , �
<br /> State License# t20���2 �3 y Expiration Date: 3-3��- �ai0 �
<br />��- Phone: �- �� �7 office cell ¢�
<br /> Mailing Address: ,� F ,� Cit : ,-,�,� ZIP: r - �
<br /> Contact Person: 2�,�,,, f�p P„s,�,,J Applicant is: ontracto / Homeowner �c���ie o�e�
<br /> Email and/or Fax:
<br /> �Y
<br /> PROPERTY OWNER INFORMATION: �'
<br /> Name: ��'�Z o,1� �
<br /> -TiTm P
<br />$� Phone (daY)� �.5 ` - �7,3�` ` / �
<br />: �
<br />�,., ^ddress: ��SUI L�?�S � � .�' � �itv��r�sL�,�r� ZIP� ��
<br /> Email and/or Fax � �"
<br /> F '-:
<br /> PROJECT INFORMATION:
<br /> Type of Project: I Any earth movement may require �
<br /> MCWD review&permits
<br /> ❑ Door(s) �Remodel ❑Water Damage �,
<br /> i Minnehaha Creek Watershed District(MCWD)
<br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd f,
<br /> Deephaven, MN 55391 '^
<br /> z s ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 �
<br /> . Fax: 952-471-0682 ��
<br /> ��� ❑ Re-roof ❑ Fire Damage �
<br /> www.minnehahacreek.orq ,,
<br /> 4 � Overall Project Description: /f/�t�> �i ���c;� ; ��,,�� �,w��, L���l - /����l,�c/` i%t�,� ,(�.�f-h �
<br />�. ' Estimated Construction Valuation of Project(exc uding land) $ /QD Un�7 �
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<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
<br /> but to reject it until it is complete; �
<br /> ��
<br />'?x� • 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 />,. . �;;
<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 refuse to su I the information,the a lication ma not be issued.
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<br /> ApplicanYs Signature: ' �v��- � �L� Date: �-j-(� � �".
<br /> �:;
<br /> Last Updated: 05-04-2009 �
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