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<br /> � Cit of Orono }
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<br /> Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.) �,
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<br /> �O� Mai��PO Bo r66 � Permit number: 20j0-003�(0 ��
<br /> 0 �� Q , Crystal Bay, MN 55323-0066 Date received: S J`�-�� �;�
<br /> ��� � ,� �' �,� Street Address: Received by: [J
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<br /> �nt '1 �" �� 2750 Kelley Parkway Plan review fee: � �Q I°n ��/ 1'Cc��1
<br /> �kESHOg'� Orono, MN 55356 ��
<br /> -- Total Fee: 201 D-00 305
<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: �C"i' � � ��` �� , /� � c� l
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No
<br /> If yes, a special event permit is required with Police Department 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/APPL CANT INFORMAT N:
<br /> Name: � �
<br /> State License# �r " ' Expiration Date: ,3 i �j Z »;.
<br /> Phone: -� ' -�- office ' "i l�_ cell "�
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<br /> Mailing Address: � � .�� Cit : � ,� � ZIP: ` �<< `�_�
<br /> Contact Person: Applicant is: Contracto / Homeowner (Circle One) �
<br /> Email and/or Fax: f,,,,�,/�, ���,�,�.�,�, �X �j`r7J �/�l� ��r� �
<br /> PROPERTY OWNER IN OR AT�I�N: �'
<br /> Name: �ci � f�-�i�SC��I y�"
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<br /> Phone (day): L�� f�-���.���� �
<br /> Address: ����,��,�T ¢�,J� City:�;�`.��j ZIP:S�`}'J/
<br /> Email and/or Fax ,��i1��1y�,� ��,/ �n� €
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<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) ❑ 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: • - �, � �� � ,� � , � %z � � �, � �(�- < < �
<br /> Estimated Construction Valuation o Project(excluding land) $ ��^7�, �a �
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<br /> APPLICANT ACKNOWLEDGEMENT: y�
<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;
<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.
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<br /> Applicant's Signature: Date: �`����1/v
<br /> Last Updated: 05-04-2009
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