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/33�- s�u� � . <br /> ` � ' City of Orono <br /> 6uilding Permit Application for Internai Work <br /> (windows� doors, siding, re-roof, etc.) <br /> �----`,:-, �a;r,�qdaa�ss: <br /> �'���T��� PO Box 86 Pe�+�t number, d D - D/D <br /> 0� Crystal 6ay,MN 55323-0066 Date reoeived: <br /> ' y. {.,� Q <br /> ,`� r • iF" � S`/tlW�W��. �IVI�T.fYed�. <br /> 1� 0 275tl Keiley Parkway Plen rovlew fee: <br /> �`��o'� Orono,MN 55356 <br /> � Main: 952-249-4600 Fax: 852-249-4616 .ci.orona.mn.us Totsl Foe: � ( (0 1� � <br /> This application form must be campleted in full and ail required infomtation must be submilted_ <br /> Incomplete appllcatlons wi11 be returned. (Pleese p��r) <br /> GENERAL INFORMATION: <br /> Job Site Address: Q/ <br /> Will this be a Parade of Homes, Remodelers Sho se Home or other Display Home? Yes No <br /> KY'�s�a BPeda/a►rent pen»�is reqaired wlN,PoNae ber,ertmer�r end Ciry Cound�approva160 deYB P�ro the avent Shu(He bus aeivlce will be <br /> requl/�d unles8 appJkarlf demonetrstes suNident on-sPoa perking i8 avaN9b/e. Non- <br /> Pen►►itfed e�ne►Ke wlNnot be aUowed. <br /> CONTRACTOR/APPLICANT IN ORMATIQN: <br /> Name; n <br /> SEate Licensa# <br /> Phone: Expiratlon Date: <br /> Mailing qddress: � °ff �II <br /> Contact Person: c� � 21P_ <br /> Email end/or Fax: APP���nt is: n / Homeowner �ctrde o,,.� <br /> PROPERTY OWNER INFORAAA I <br /> Name: ' � <br /> Phone(day): <br /> Address: Ci : �Q s <br /> Email and/or�ax ZIP: <br /> PROJECT INFORMATION: <br /> 7ype of ProJoct; <br /> Any earth movement may require <br /> ��OpKs� ❑Remodel MCWD revlaw 8 parntlts <br /> ❑Water Damage <br /> ❑�ndow(s) ❑Repair ❑Storm Damage M�"^�aha Creek Watershed Dlslrict(MCWp) <br /> 18202 Mlnnetonka Blvd <br /> ❑Siding ❑Restoretlon ❑O��(��� �eePhaven,MN 55391 <br /> Re{oOf , Pho11e:952-2a71-0662 <br /> ❑Flre Damage , wWw, innehah�c ek.or <br /> Overall Pro ect Descrt tion: -�� <br /> Estimated Construction Valuatlon of P� t excluding land) : �.. <br /> oO b. <br /> APPLICANT ACKNOWL�DG�MENT: <br /> • �es to provide all ir�formaqon requlred o��quested by the Bu(Iding Oepartment; <br /> • Cerpfles that the intamation supplied Is bue and oonr�t���t ot hismer kriowledgs. The ePplicent recognizes Wat lhey <br /> are solely re�onsible fa s�bmimng a oomplete applicaqon being awaro that upon failuro to do so, 1he stgff haa no alt�,eG� <br /> but to�Jed il until it Is complete; <br /> � Some or all of the Informafion dlet you are aeked to pp Y <br /> coMidandel_ Prlvate data is �nforma6on wh;q� ��e °� � a lication Is dassified b State law as either private ur <br /> data. Conflderdial dsta is IMortnation which generelly cannot De gw n�to e�ither the� publlc�or tl�e s bj ct of Ihe dala�tOur <br /> P��po�e end intended use of this Infom�adon Is 10 annuslly update our necads and ,mooMs of other govemmental agencies <br /> uired lew. If ou�eluse�su I the InMrtnadon Ihe a icaUon not ba Issued. <br /> Applicant's Slgnature: � <br /> Date: �� <br /> t.��upda�ed: 05-04-2ooa <br /> ' I <br />