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• (aliA__/ <br /> City of Orono ` _afj8/z, <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: <br /> ‘111"OO PO Box 66 Permit number: aQ/Q-(J�/ S <br /> 3$ <br /> Crystal Bay, MN 55323-0066 Date received: 57/7// <br /> ,"` Received by: �fi/7g <br /> A �ij Street Address: <br /> �„^,��S'�� 2750 Kelley Parkway Plan review fee: <br /> 9kEsOrono, MN 55356 <br /> Total Fee: >� /171. 7 A. <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: i <br /> Job Site Address: 4-64-c (,Jw -Ota u-___. Z-Q(_.0 <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 will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: (p(Z 77_3 ----523c1 <br /> Name: CikEq 4 DAK, 1 )=G.u_EAISCIZ I — <br /> State License# Expiration Date: <br /> Phone: (office) 95L_ -7(p--b---7 LS celll <br /> Mailing Address: s ck- c�S cxAoay.ti City: �' <br /> Contact Person: (z 1= ILE/hhEP---� Applicant is: Contractor / H mem owne (Circle One) <br /> Email and/or Fax: _ v•---434--- --0.0.—Si \,....._w—A---, 11-01".---- <br /> PROPERTY OWNER INFORMATION: CgSL 7S- ���4' <br /> Name: �.f�E 4 l�Nk )tel t zNit(� �� <br /> Phone (day): Cp> 9s-a.._ 4-7u — to"-(,S— (r•) 1,(2_ "7 Z -- 3 <br /> Address: 40115 ti3 2-1-.0 ;' -- R--p 3 City: Q — - -c ZIP: Sc-3S� <br /> Email and/or Fax crpci , lo- 'v,,005>; AN ,---. ' <br /> 'N---- <br /> -C-01._ is-a_ 475- -69e 4— <br /> PROJECT INFORMATION: <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) `j Repair IZ�'C'� CI Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ 'go C'C, <br /> 1 <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; <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 /> required by law. If you refuse to supply the information, the application may not be issued. <br /> Applicant's Signature: ()/ 1G7 <br /> .1C Date: e� r ) '- 7_0 t 0 <br /> 1)0 <br /> Last Updated: 05-04-2009 <br />