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- ,=�2�^'�� �.r,.; .�, '�a.��? <br /> j`t.., C . ` . . �� h � '�� � <br /> �.k <br /> City of Orono � ������� <br /> Building Permit Application for Internal Work �� � �''� � � �' <br /> (windows, doors, siding, re-roof, etc.) � <br /> :� <br /> Mailing Address: Z �' <br /> g,�,� POBox66 Permitnumber: 0/U —O� � � � <br /> r � ^ Q Crystal Bay, MN 55323-0066 Date received: � � <br /> ` �: <br />���� �� Received by: <br /> ,� ��✓��1`��, �, Street Address: '^� <br /> �� �'�,c, ti 2750 Kelley Parkway Plan review fee: <br />�'� t9'kESB��`'�G Orono, MN 55356 �Q <br /> � Total Fee: '` �)-"], (S <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. (P/ease print) :;� <br /> � GENERAL INFORMATION: � ;� <br />� Job Site Address: �( S �'�'` -�cV�, � � <br />��' Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o <br /> � .. <br />'rk�*�! If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service ill be �.� <br />�`,. required unless applicant demonstrates su(ficient on-site parking is available. Non-permitted events will not be allowed. � <br /> ` CONTRACTOR/APPLICANT INFORMATION: � � <br /> Name: ��� �j�S��G�Z�=� <br /> State License# (��,3 �,57`� Expiration Date: <br /> Phone: ?C�j- •7�j - � p office cell <br /> Mailing Address: S I � ����sr�i7� S: Cit : r �h�'�� ZIP:S S �s`�' <br /> ` Contact Person: �� Applicant is: ontrac Homeowner (Circle One) <br /> s„ <br /> Email and/or Fax: ���-- �f7� � �v <br /> : PROPERTY OWNER INFOR ATION:� <br /> '' Name: �(�� � �.-by'�� � <br />�,� Phone (day): �j SZ� �7 -• So b <br />- Address: 2 i�{S (�f'�^ �v� City: �r�� ZIP: S S 3 S � <br />;;": <br /> Email and/or Fax ;: <br />;�; PROJECT INFORMATION: <br /> ���' Type of Project: Any earth movement may require <br />�::`, <br />�r MCWD review&permits � <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 />�>, e-roof ❑ Fire Damage www.minnehahacreek.orq <br />:+ii: <br />��: Overall Project Description: <br />�: Estimated Construction Valuation of Project(excluding land) $ � �v�o ^ � <br /> � �� <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 /> r- are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative <br /> F ' 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 refuse to su I the information, the a lication ma not be issued. �< <br /> F � <br />�}' � � < x� <br />_�� ApplicanYs Signature: Date: � '' Zy - �v � <br /> �'; <br /> ;s' Last Updated: 05-04-2009 �;' <br /> ;�:� ` �,� *c� ���. �t �'���:�, �� * �. A <br /> ` Y�`A£ �) <br />. . .,. . . .'��6s.t ., .��: ._ +:� .�.,��,.a��..::��.aau�Ee�.s�,.,�6i��'�.r. a�r,. �.f§k.��5.�. �.�_ <br />