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�► City of Orono . ��,� <br /> Building Permit Application for Internal Work � <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number. ������ �- �(p � �'�. <br /> �,L,�,� PO Box 66 . <br /> Crystal Bay, MN 55323-0066 Date received: � <br /> O �`� �, O Received b <br /> � � �?, a, Street Address: Y� <br /> �' ' "�' �ti�' 2750 Kelley Parkway Plan review fee: <br /> �t`�kEsHo�`'`� Orono, MN 55356 C � <br /> Total Fee: � � L�� 0 <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 /> Job Site Address: ' � �; ' ,-,�, - �� r`/ <br /> Will this be a Parade of omes, Remo elers Showc e ome or other Display Home? ❑ Yes o <br /> !f yes,a special event permit is required with Police Departmen and City Council approval 60 days prior to the event. Shuttle bus service wil!be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: , � <br /> Name: �� : � �.GY<tY � �'lC=. <br /> State License# - � "��' Expiration Date: �� � � <br /> , .,, <br /> Lead Certification Number: 1 y1{j�•��j _ ( Expiration Date: �' • �) ; <br /> (for work on homes that were constructed prior to 1978 µ <br /> Phone: ' ��- � �� (office) (cell) � <br /> Mailing Address: Ua � " � �. City: �. , � . ,z��(ZIP: r�J/ � <br /> Contact Person: Applicant is: Contrac or / Homeowner (Circle One) � <br /> Email and/or Fax: �j,.�_ ,t/��, _ r-j�b � <br /> PROPERTY OWNER II�FOR ATION: �? <br /> Name: �� �� � � � <br /> Phone (day): � . �j .. � � <br /> Address: _.` , " , � , City: �,yl �q,`� ZIP: �J`��,�(� <br /> Email and/or Fax <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 �torm Damage 18202 Minnetonka Blvd <br /> Restoration Deephaven, MN 55391 <br /> ❑ iding ❑ Other: (specify) Phone: 952-471-0590 <br /> Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.orq � <br /> Overall Project Description: ~' - ;� - ,,� � <br /> , � . , -'a-�'- , � _� <br /> Estimated Construction Valuation of P ' ct(e uding land) $ � <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; ,7 <br /> ,, <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 informati n is to annually pdate our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I the nform 'on, t lication ma not be issued. <br /> �'' � �� <br /> ApplicanYs Signature: � �� Date: i � <br /> Last Updated: 03-01-2011 <br /> � <br /> t � <br />