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�- City of Orono <br /> . Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address � <br /> Permit number: <br /> ��v 0,�� PO Box 66 �;� <br /> Crystal Bay,MN 55323-0066 Date received: ' <br /> ,� � ;��, �, Street Address: Received by: <br /> �'�,c, ''�' ti�' 2750 Kelle Parkwa <br /> '� a `yG Orono, MN 55356 Y Plan review fee: <br /> �ESHo4 <br /> Total Fee: � <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. (Please print) <br /> GENERAL INFORMATION: � ` � ± <br /> s <br /> Job Site Address: `��� `�v'v'�I ,�-t_G� ,� <br /> S <br /> Will this be a Parade of Homes, emodelers Showcase Hom r other Display Home? ❑ Yes o ,;, <br /> !f yes,a special event perrnit is required with Police Department and City Co cil 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. R; <br /> �;, <br /> r <br /> CONTRACTOR/APPU( T, INFORMATION: � <br /> Name: �l������'r�- � <br /> �� <br /> State License# ������7� Expiration Date: i�; <br /> Lead Certification Numbe : Expiration Date: a� <br /> (for work on homes t�►at were consfructed prior to 1978 � <br /> Phone: ������(�—��3 S/ (office) (cell) � <br /> Mailing Address: Cit : ZIP: <br /> ,'� <br /> Contact Person: , Applicant is: on� / Homeowner (Circle One) � <br /> Email and/or Fax: � <br /> . � <br /> PROPERTY OWNER INFOR A�ION: � <br /> Name: — ,c� l�: a; <br /> ,� <br /> Phone (day): C�S _ � <br /> Address: ( City: �✓\f� ZIP: � <br /> Email and/or Fax � <br /> � <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require ,,� <br /> ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: �'' <br /> Minnehaha Creek Watershed District(MCWD) �� <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd �� <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> (�-�te-roof ❑ Fire Damage Fax: 952-471-0682 <br /> V www.minnehahacreek.orq � <br /> Overall Project Description: - . -- w �, _,�l���.j,� <br /> Estimated Construction Valuation of Pro'ect exc udi fand �� � <br /> 1 ( 9 ) s <br /> '� <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 /> 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 refuse su ! e i ormation, the a lication ma not be issued. <br /> Applicant's Signature: Date: �;�_ <br /> Last Updated: 03-01-2011 � <br /> � <br /> s3 <br />