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_ _ - ' w�� <br /> ��> <br /> ._ s � . <br /> � ` City of Orono � ' <br /> � , <br /> 4 <br /> � , �`:: <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> �,i,�,� PO Box 66 <br /> � �\ Q Crystal Bay, MN 55323-0066 Date received: <br /> i s , <br /> � � ��< <br /> Received by: �} <br /> � �' 4 ;� �. Street Address: <br /> �� ''! G�F 2750 Kelley Parkway Plan review fee: � <br /> �9kEsfIO�'� Orono, MN 55356 �' <br /> Total Fee: � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us r:-;�. <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 /> f <br /> �' Job Site Address: �7',3� � t`� /�,� /(� ���� �,�c ��/ ��5� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes "� <br /> '` ❑ No <br /> lf yes, a special event permit is required with Police Department and City Council 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. <br /> ' CONTRACTOR/APPLICANT INFORMATION: <br />�.;; <br /> Name: _ �� [x�� <br /> State License# Expiration Date: y�r; <br /> Phone: office cell <br /> Mailing Address I ` C"�(I� Cit : �(�e ZIP: SS`�/�!� ' <br /> Contact Person: Applicant is: Contractor Homeowne ��ie one� ; <br />��> Email and/or Fax: <br />�y'� <br /> t;-' PROPERTY OWNER IN�RMATION: �; <br />��� Name: J� � � � <br />�` E. <br />�';' Phone (day): 2- -�� � <br />� Address: �-f?l,� 6�,(�� Cit � O��O ZIP� �`y\- ` <br /> k��'��. J l '1 �� <br /> x�,, Email and/or Fax <br />_,��. <br /> ` PROJECT INFORMATION: �a,-r, /Ze— S��e � <br />� ' �; <br />�', Type of Project: Any earth movement may require <br />��,- MCWD review&permits <br /> �Door(s) 2 ❑ Remodel ❑Water Damage <br /> Window(s) 2 ❑ Re air Minnehaha Creek Watershed District(MCWD) <br />�~• � p ❑ Storm Damage 18202 Minnetonka Blvd <br /> z, <br />-� �/ Deephaven, MN 55391 <br /> �,Siding � / S� ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br />,�` Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> �` Overall Project Description: G✓G / �cG�„ �„ <br /> '.��,.5 he� cw S�� <br /> Estimated Construction Valuation of Project cluding land) $�qoa,od /�.�f�,�,/ <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 r <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 enerall cannot be iven to the ublic but can be <br /> 9 Y 9� p 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 /> ApplicanYs Signature: Date: ���J- � V ` <br /> \ <br /> Last Updated: 05-04-2009 y V ss . �P .y`� �= �� <br /> M � <br /> ��, ��' <br />