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�� <br /> City of Orono <br /> . " Building Permit Application for Internal Work <br /> �, <br /> (windows, doors, siding, re-roof, etc.) ;, <br /> Mailing Address: Permit number: � <br /> g,�,�. PO Box 66 � <br /> 0 � O Crystal Bay, MN 55323-0066 Date received: � <br /> ��`��� � Received by: � <br /> � � ���G�:> o. Street Address: <br /> �',�, '� s� Gti`� 2750 Kelley Parkway Plan review fee: <br /> t�kESH�g'� Orono, MN 55356 <br /> Total Fee: <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: �F <br /> Job Site Address: l��'j '_�t-�ir�� �jl_c: �iJ , <br /> � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No ':� <br /> ,x <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 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 /> Name: ��` �' � �?������� �C,C_ <br /> State License# Z�J3"���J j Expiration Date: ' 3� // <br /> Phone: �,jl 75,:; �3�'7 (office) %/�'���:� J3Q� (cell) � <br /> Mailing Address: �S;,u'j r%�fTc��<.�/ �� c_,v, City:_/�'�,�,' ZIP: ,��;:jv'� .� <br /> Cont�ct Person: J�-�/-�--� .J�.��iyjC, Applicant is: �Contracto� Homeowner (Circle One) � <br /> Email and/or Fax: �j'�Z j��� Z'�� / ;� <br /> PROPERTY OWNER INFORMATION: ,"��' <br /> Name: l/f�r � C� �� ��4L�/�/ � <br /> Phone (day): `fi52�� �771,� -1C�/I � <br /> Address: ���'' <br /> C,GZS� �l��'l%iL�,�-�/l� i�i�. CitY� �',�i�� ZIP: ]�� ��; / �? <br /> Email and/or Fax <br /> :� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require '� <br /> MCWD review&permits ;� <br /> ❑ Door(s) ❑ Remodel ❑Water Damage � <br /> .� <br /> Minnehaha Creek Watershed District(MCWD) =-� <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ' <br /> Deephaven, MN 55391 � <br /> �R <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 � <br /> Fax: 952-471-0682 � <br /> {4 <br /> Re-roof ❑ Fire Damage www.minnehahacreek.orq � <br /> � <br /> Overall Project Description: -7"O"j,,C� /lC ('�'� � <br /> Estimated Construction Valuation of Pro'ect excludin land $ '� ' '� '' " <br /> 1 ( 9 ) Ci(.J,t�'� �� <br /> � <br /> APPLICANT ACKNOWLEDGEMENT: '' <br /> • Agrees to provide all information required or requested by the Building Department; `� <br /> i� <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 altemative � <br /> but to reject it until it is complete; � <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 r <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> '� <br /> re uired b law. If ou refuse to su I the information, the a lication ma not be issued. � <br /> �------._ /� / <br /> ApplicanYs Signature: Date: ��/����✓ � <br /> ���._�� � <br /> Last Updated: 05-04-2009 <br /> � <br /> � <br />