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<br /> City of Orono ��
<br /> - � Building Permit Appiication for internal Work `�
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<br /> (windows, doors, siding, re-roof, etc.) �
<br /> Mailing Address: Permit number: v� � `�v � � %
<br /> O�v D,�O PO Box 66 �
<br /> Crystal Bay, MN 55323-0066 Date received: � �
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<br /> ����- Received b
<br /> .� .��. s, Street Address: Y�
<br /> x'� '�� ��titi 2750 Kelley Parkway Plan review fee:
<br /> �`��Esxo4`' 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: � t
<br /> Job Site Address: �C ( J 7 � _n��/o,, �1 ��,� �/! �y;�j
<br /> Will this be a Parade of Homes, Remodele Showcase Home or oth re Display Home? ❑ Yes ❑ No ;,�
<br /> If yes,a special event permit is required with Police Department and Crty Counci/approval 60 days prior to the event. Shuttle bus service wil!be
<br /> required unless applicant demonstrates sufficient on-site parking rs available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: �����,�.� ���,����,�_�_?-�,.w
<br /> State License# ������ ���� Expiration Date: � - -;; � i 7_. �
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: -7,�,<; -- � 7 � - ;�7�.�' (office) (cell) ;
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<br /> Maifin
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<br /> • ,�i�/�� !,� ,.� �t�c �e ��{ r' ll.>� �ty: '.�t� Cz �, ZIP: 7!�l, "
<br /> Contact Person: T,,r, (�,_;, t �;,�_-,. Applicant is: rac Jr l I Homeowner (Circle One)
<br /> Email and/or Fax: �� �_ -,�� s - s��, Z �'
<br /> PROPERTY OWNER INFORMATIO�1:
<br /> Name: /
<br /> _ L r ��. � I ;��� n �
<br /> Phone (day): 7(„3 - 4� 7 S -� ��' `:
<br /> Add�ess: � �J� -'-5 �>,�,w�>c��� l''� City: � � ZIP: r
<br /> rt�/�G
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
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<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) ^�2epair ❑ 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: � 5��,, �t �t, ,�.,� �� r S�.,,,'�,-f ��-� �
<br /> Estimated Construction Vafuation of Project(excluding fand) $ � �J�; "'
<br /> APPLICANT ACKNOWLEDGEMENT: ' �
<br /> • Agrees to provide all informafion 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 informafion 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 informa�ion, the a fication ma not be issued.
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<br /> AppficanYs Signature: ' �. Date:
<br /> Last Updated: 03-01-2011 �
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