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<br /> ' City of Orono
<br /> Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number: �
<br /> g,0,�. PO Box 66 �
<br /> Q � O Crystal Bay, MN 55323-0066 Date received: �
<br /> a �3�G�;� �, Street Address: Received by: i�,
<br /> �'�, fz `6`� �ti 2750 Kelley Parkway Plan review fee: ���
<br /> L9kE5i;�4'� Orono, MN 55356
<br /> — Total Fee: 4
<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 /> r�
<br /> Job Site Address: /'� � ��.,;� ;�
<br /> o� �=� i I �c' .� " �'
<br /> Will this be a Parade of Homes, Remodelers howcase Home or other Display Home? ❑ Yes ❑ No �
<br /> If yes, a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will 6e ��
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION: -
<br /> Name: ,�v�l-ti �o:�,cs /nc�. ;
<br /> State License# Z 3S/3�iG Expiration Date: 3-3i-/Z
<br /> Phone: 9SZ -�6�-5�y�.5' (office) Ei,2 -ySa- ��fG (cell)
<br /> Mailing Address: Z� r C��L�� C'���,� �L��� City: C°�,�G�,e ZIP: s�3.:S�
<br /> Contact Person: �,�, ,L�y.��� Applicant is: on rac / Homeowner (Circle One)
<br /> Email and/or Fax: ,Q1i,�,�..-,���hE'S �`' £tii.3�,L .C.� � �}/G , c'o� ISZ--3�i- y y�s'"
<br /> PROPERTY OWNER INFORMATION: �
<br /> Name: �,. ��,�.. �� ¢ .�v � �G�.+, Sc�,�
<br /> Phone (day): �� - �i�._ y��e•
<br /> Address: �",G• 5�i �r/� ff/it Clty: �/�Gy�i ZI P:
<br /> Email and/or Fax s�s; � f�L,e,,�,� ,3 C�' iy,c,h'S�. , �"��,
<br /> PROJECT INFORMATION:
<br /> 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) J�'Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> Deephaven, MN 55391
<br /> ❑ Siding ❑ Restoration �Other: (specify) Phone: 952-471-0590
<br /> /-�p Fax: 952-471-0682
<br /> ❑ Re-roof ❑ Fire Damage c. ����' �/G���n�v.<.' www.minnehahacreek.orq
<br /> Overall Project Description:
<br /> Estimated Construction Valuation of Project(excluding land) $ ,�G��.c��
<br /> f.
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department; �
<br /> �
<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; 4
<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 /> Applicant's Signature: �� Date: �U ��z �/U
<br /> Last Updated: 05-04-2009
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