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;� <br /> � t - City of Orono � <br /> Building Permit Application for Internal Work � <br /> �, <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: �l�� <br /> �,L 0,� PO Box 66 <br /> � 0 Crystal Bay, MN 55323-0066 Date received: �/ / <br /> a � ��-�+" s. Street Address: Received by: <br /> �' A"�� �ti 2750 Kelley Parkway Plan review fee: f� <br /> �t�'kESHo�`'� Orono, MN 55356 � <br /> Total Fee: ��D, �5 :� <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: ` �D `z� <br /> Job Site Address: ��l� �L ��`� �''��c�u �% - ��%7y�'��. ,!� <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 approvaf 60 days prior to the event. Shuttle bus service will be � <br /> required unless applicant demonstrafes sufficient on-site parking is available. Non-permitted events will not be allowed. i? <br /> CONTRACTOR/APP�CANT INFORMATION: / <br /> Name: �vt��f�G-CSr' e�c:�� %"y S,d�� �/kci�i� <br /> State License# ��p �;� 7l � Expiration Date: �-- � - <br /> �� � � <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 -� <br /> Phone: (office) � � �" v�,�-�-5� � (cell) <br /> Mailing Address: Lf_S/ C�e�u.-P �- City: ,p� ZIP: ,S'�.fCy� <br /> Contact Person: �:��,�� Applicant is: to / Homeowner �c�r�ie one� `� <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATIO : <br /> Name: S��{� ��',l� � <br /> Phone (day): �S a - y 7� � 7�Y <br /> Address: af�G.3 Sc�g�,i(;,.f�.e ,�:, City:L�i•'� l--�l.� ZIP: <br /> Email and/or Fax <br /> � <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 ❑ Storm Damage 18202 Minnetonka Blvd '`' <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 '� <br /> �Re-roof Phone: 952-471-0590 � <br /> ❑ Fire Damage Fax: 952-471-0682 �� <br /> www.minnehahacreek.orq � <br /> Overall Project Description: � -�r G{t- . � %�;� f �r�G�/ S/�((�C '`� <br /> Estimated Construction Valuation of Project(excluding land) $ � y; �7�;�Q '� <br /> x <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; '' <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. Confidenfial 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 govemmental agencies � <br /> � <br /> re uired b law. If ou refuse to su I the information, the a lication ma not be issued. <br /> /� Y <br /> Applicant's Signature: ��/��/ Date: v � ��` �� � <br /> �% <br /> Last Updated: 03-01-2011 :� <br /> s' <br />