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ri <br /> Oct-04-2010 02:01 PM American Building Contractors 952-707-9925 �.,� / vi 'y / 1/1 <br /> k IVB"/ <br /> .r� 4A <br /> 13 3 1 2 City of Orono I <br /> Building Permit Application <br /> Mailing Address: Permit number. C73o/6—i3 g <br /> / •,0 Ai,. PO Box 68 <br /> 0 Crystal Bey,MN 55323-0066 Date received: /0/L/ /LQ <br /> `,t1. Received by: ` G <br /> `i,► :. Street Address <br /> II J,, a A, o 2750 Kelley Parkway Plan review fee: <br /> z Orono,MN 55356 <br /> Total Fee; A 3 3 , <br /> Main: 952-249-4600 Fax: 962-249.4616 www,cl,crono,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 ress:INFORMATION: `7 5 0 ,�vtie- Od1Y) ,p 1 0 <br /> Job Slte Address: pL�-/ I� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> 0111 <br /> If yea,s spacial event permit Is required with Police Department and City Council approval 80 days prior to the event. Shuttle bus service ba <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP ICANT INFORMATIO`' '9,,—.21—7„, 7 r�' <br /> Name: ' , rc c sLmiric 1 C4`01-Wet eta irS -ii`-l_. <br /> State License# . W ,. Expiration Date: Le.,[—/r <br /> Phone: 'S';1,-• . ( -St (office)_ (cell) <br /> Mailing Address: 'a,9'60 'mote i et(L fab(. Cl . i {ri'//dr ZIP:55g3 7 <br /> Contact Perso • 4„A LJ:c Applicant Is: on rac o / Homeowner (owe ono <br /> Email andlo&FPi 95a--707. ,491"'Y <br /> PROPERTY OWNEA. INFORMATION: <br /> Name: <br /> loar-�- �� <br /> Phone(day); <br /> Address: t�Ja�er City: Q rip r‘o ZIP:55 3s1 <br /> Email and/or Fax <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) ❑Repair 0 Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55381 <br /> ®Siding IM Restoration ['Other: (specify) Phone: 052-471-0590 <br /> Fax: 952-471-0882 <br /> Re-roof ❑Fire Damage www.minnehahecreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ j , a„$© �� AJA/ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide ell information required or requested by the Building Deportment; <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 <br /> Signature: 4i. Date: 0'-e("rU <br /> _ <br /> r:, ,;,,. FoTetrm : <br />