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<br /> ��� � �" City of Orono ��
<br /> �
<br />�` Building Permit Application for Internal Work ,�
<br /> �, (windows, doors, siding, re-roof, etc.)
<br /> f�.' Mailing Address:
<br /> f
<br /> 0�.,�,�0 PO Box 66 Permit number: / p -O G
<br /> � Crystal Bay, MN 55323-0066 Date received: ��2`j'�/� �
<br /> � �
<br />,�; a �' ���ti�' s. Street Address: Received by: ���
<br /> �:
<br />� �'�,n � '9�' �� 2750 Kelley Parkway Plan review fee: �k
<br />���' le '� Orono, MN 55356
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<br /> Total Fee: ���� �D ,�
<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 /> °� : �� �
<br /> .� GENERAL INFORMATION: , •
<br /> �
<br /> � Job Site Address: �j� � � �p , �� (P `
<br />�F' Will this be a Parade of Homes, Remodelers Showcase Home or other Dis la Home?
<br /> �� p y ❑ Yes ❑ No ��
<br /> � /f yes, a specia/event permit is required with Po/ice Department and City Council approval 60 days prior to the event. Shutt/e bus service will be '�
<br /> r�. re quired unless a p plicant demonstrates sufficient on-site parkin g i s av ail a b l e. N o n-p e rr n i tt e d e v e n t s w i l l n o t b e a U o w e d. �..
<br /> .�.
<br />� ' CONTRACTOR/APPLICANT INFORMATION: �
<br /> ;''
<br /> Name: ��L° I�./�' , ��,
<br />��' State License# a o�3�sa� Expiration Date: ,�p i� �`�.
<br />,�� Phone: (�/ -��a-j0! U (office) (cell) �
<br /> y�` Mailing Address: � � �' . }�Sl, Cit : �4,eoYc ZIP: S s'o /
<br /> x y' Contact Person: c- C� C- ��-i� Applicant i ontractor / Homeowner (Circle One)
<br />�; Email and/or Fax: � � ,,�.� 6 - 3.- -2 � I
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<br /><t��;� PROPERTY OWNER INFORMATION:
<br /> - �-- � � �:
<br />�:.< Name: j' �i� �'�c�
<br /> ,<� Phone (day): 6 i,2- 3�8 -�,Ly� �
<br /> Address: 3� S—� �'o ,C� � City: �,e�civc, ZIP: S S-3.s�
<br /> � Email and/or Fax
<br />�,
<br />��,;t:
<br />�t: PROJECT INFORMATION: F.
<br />�,,t. Type of Project: Any earth movement may require �
<br /> ; � 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 />��. Re-roof ❑ Fire Damage www.minnehahacreek.orq
<br />�:� Overall Project Description:
<br />`� Estimated Construction Valuation of Project(excluding land) $ /� �o �, �' �
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<br /> - �_;•
<br /> �: APPLICANT ACKNOWLEDGEMENT: �
<br />� `.
<br /> s • Agrees to provide all information required or requested by the Building Department; �
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<br /> r'� • 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 to su I the information,the a lication ma not be issued.
<br /> _ . �
<br />� ApplicanYs Signature: �-, �i� , Date: � � a p � x�
<br /> �
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<br />�. Last Updated: 05-04-2009 "�
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