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<br /> C�ty 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 /> Mailing Address: Permit number:
<br /> �yv�,� PO Box 66 �
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<br /> Crystal Bay, MN 55323-0066 Date received:
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<br /> � �'�? 4,.;::;�. �, Street Address: Received by:
<br /> �' � .�"y� Gti 2750 Kelley Parkway Plan review fee:
<br /> L9kESH�4� Orono, MN 55356
<br /> Total Fee: �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
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<br /> This application form must be completed in full and all required information must be submitted. <'
<br /> Incomplete applications will be returned. (P/ease prinf) '�
<br /> GENERAL INFORMATION:
<br /> Job Site Address: �-;c�.7� ��� qa,L �✓v��s ���' . ;�
<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 �Y
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. � ;;�
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<br /> CONTRACTOR/APPLICANT INFORMATION: j
<br /> Name: �/�te,� ��:�s����.`E��-� �
<br /> State License# �,�,3 i 5 7 S Expiration Date: �'-,�i - i a--
<br /> Phone: '7C�3- - �7u� office cell
<br />_ Mailing Address: �i T ' ' � �. �;�, � i��' Cit � ZIP: "S,3S °�
<br /> Contact Person: /�%c,� � ,L. Applicant is: on ra / Homeowner (Cirde One) `'�
<br /> Email and/or Fax: ��,3_y�y-��;,�a o� ) �
<br /> PROPERTY OWNER INFORMATION: �
<br /> Name: �/�;F_2,f G.�.�-�'
<br /> Phone (day): ���� - S4� -,�'� S'� E�"
<br /> Address: ���,� S;��,,,�",�,�� �� City: D�'-�-^ v ZI P� �
<br /> Email and/or Fax �
<br /> PROJECT INFORMATION: f�
<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 /> �e-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> Overall Project Description: T"��� �,,,/��' ,/�./�� ������,� � :
<br /> Estimated Construction Valuation of Project (excluding iand) $ �'��? �"vv, `'`' �5
<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 ;,.
<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; �
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<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: �1��� ,� �����— Date: �� � l ��iU �
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<br /> Last Updated: 05-04-2009 $'
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