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<br /> , City of Orono ���
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<br /> Building Permit Application for Internal Work � �� ��
<br /> ��
<br /> �:
<br /> (windows, doors, siding, re-roof, etc.) �
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<br /> Mailing Address: Permit number: �
<br /> Y �v�,� PO Box 66
<br />� �` Crystal Bay, MN 55323-0066 Date received: a O/b —(�O �
<br /> � ���a , �
<br />�'�y a �' s�'.;' s, Street Address: Received by:
<br /> �' � e�� G��' 2750 Kelley Parkway . Plan review fee: �
<br /> �
<br /> L�kE3H�4'� Orono, MN 55356 #
<br /> Total Fee: ,�l`� � � ,�
<br /> Pf.. Main: 952-249-4600 Fax: 952-249 4616 www.ci.orono.mn.us T / � � �
<br />�,:..; This application form must be completed in full and all required information must be submitted. :�
<br />�t; Incomplete applications will be returned. (Please print) ��
<br />� ` GENERAL INFORMATION: ��� �� ���
<br /> e Job Site Address: ^-� i � �� �I r
<br /> C�I�� �,.`��r �J�'dt � ,
<br />�'�' Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No
<br /> 6'� If yes, a specia!event permit rs required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be x
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. �
<br /> ` � �
<br /> 3,, CONTRACTOR/APPLICANT INFORMATION: �
<br /> Name: �;�:.J r� r r������� �
<br />�" State License# ��� Expiration Date: �/z i %, ,
<br /> �� , �:�� �« �
<br />�= Phone: �� �{z. c � �� office cell ��
<br />�� Mailing Address: � C�,�..,,,.� C�. N, Cit : � �:� �� ZIP: S'S � �
<br />� Contact Person: ,���. Applicant is: ��ra� / Homeowner (Circle One) ��
<br />�`�� Email and/or Fax:
<br />� ' �
<br />#� PROPERTY OWNER INFORMATION: 3��
<br />���' Name: !��c�, �.��t C� L� w� r�, � �
<br />�� Phone (day): � - �
<br />�� Address: � �,G �,��,,r r�( d� City: �� ���� ZIP: SS� S C �
<br />�, Email and/or Fax '"
<br />�o �
<br />��� PROJECT INFORMATION: �
<br />�R Type of Project: Any earth movement may require ��
<br />�` MCWD review 8�permits ��
<br />$�� ❑ Door(s) ❑ Remodel ❑Water Damage �
<br /> Minnehaha Creek Watershed District(MCWD) �;�
<br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd �
<br />�:
<br />�� Deephaven, MN 55391 �
<br />�:�;;:; ❑ Siding ❑ Restoration
<br /> s�4 ❑ Other. (specify) Phone: 952-471-0590 �
<br /> ' e-roof Fax: 952-471-0682 f
<br /> ��:,, ❑ Fire Damage �
<br /> www.minnehahacreek.orp
<br />�"�: �r
<br />�� Overall Project Description: ��
<br />��` Estimated Construction Valuation of Project(excluding land) $ "Z�Q 'ZS'�
<br /> �
<br />� ` �
<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 /> - „
<br /> ,�' are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative
<br /> Y� 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 tne 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. �'
<br /> �� �
<br /> � � � �;
<br /> "' ApplicanYs Signature: �� Date: ` � � '"i
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<br /> Last Updated: 05-04-2009 �
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