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. ; City of Orono <br /> • Building Permit Application for Internal Work <br /> ; <br /> (windows, doors, siding, re-roof, etc.) ?� <br /> Mailing Address: Permit number: �p//—��j � <br /> �v 0 PO Box 66 � <br /> Q � Crystal Bay, MN 55323-0066 Date received: -(p-�� <br /> a ��� �!� s, Street Address: Received by: � � <br /> �'�� ' '� ����' 2750 Kelley Parkway Plan review fee: <br /> �ESHO Orono, MN 55356 <br /> Total Fee: <br /> ain: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> his application form must be completed in full and all required information must be submitted. � <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL IN ORMATION: � <br /> Job Site Add ess: ��: =�Z� �� ` � �'.�� � � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes,a spe �al event permit is required with Police Department and City Council approva!60 days prror to the event. Shuttle bus service will be <br /> quired unless app(icant demonstrates sufficient on-site parking is available. Non-permitted events will not be aflowed. <br /> CONTRACT R/APPLICANT INFORMATION:/ e <br /> Name: LCh^,;1 f'N:� �-{�vL`�i�C ��-k�►r .���t✓, � ; <br /> s� <br /> State License �{':} ���i ��, ��•Z_ Expiration Date: - �3 j - / Z <br /> Lead Certifica ion Number: �,�� ��� �L .-� Expiration Date: U, - z I - � � <br /> (for work o es that were constructed prior to 1978 <br /> Phone: � � 2� - ����7 - La��� (office) (cell) <br /> Mailing Addre s: Z�� �-}��G_ i� City:(,} � 1,�, ZIP: ��,'"��� �. <br /> Contact Perso : -T� w-� Applicant is: Contractor Homeowner (Circle One� <br /> Email and/or ax: T; wt Tc'�21C � �t�IV` � c+c`�w'1 <br /> PROPERTY WNER INFORMATION: � <br /> �;h ��/� �✓�C <br /> � <br /> Name: _S <br /> Phone (day): � .� <br /> Address: ��) >?' -�c, �j �� � �/ City. ��t.J ZIP: ��� �� <br /> Email and/or F x �� <br /> � <br /> PROJECT I FORMATION: � <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 �� �a - ,y<< Phone: 952-471-0590 ,� <br /> ❑ Fire Damage GC/ ,1 Fax: 952-471-0682 <br /> www.minnehahacreek.or4 � <br /> Overall Proje Description: <br /> Estimated Co struction Valuation of Project(excluding land) $ '��G7 <br /> �� <br /> APPLICANT CKNOWLEDGEMENT: $� <br /> • Agrees 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 sole responsible for submitting a comptete application being aware that upon failure to do so, the staff has no alternative �! <br /> but to re ect it until it is complete; � <br /> • Some o all of the information that you are asked to provide on this application is classified by State law as either private or � <br /> confiden ial. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. C nfidential 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 refus mation, the a lication ma not be issued. � <br /> Applicant's Sign ture� - Date: �/� (� `� <br /> Last Updated: 03-0 -2011 � <br /> :w <br /> t <br />