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City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: a4/l--QdQ..S/ <br /> PO Box 66 i <br /> O Crystal Bay, MN 55323-006 ,'• Date received: /-2'71 - / <br /> a �`" 1 II <<�`} Received by: <br /> Street Address: ;t1 z Lo , ISIS <br /> �'•t.f4�A.' .1 2750 Kelley Parkway -" Plan review fee: / <br /> g 0og- Orono, MN 55356 41 <br /> Total Fee: 07/ i0: <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) r vi" �-7 <br /> GENERAL INFORMATI N: C/' i tel,[/ <br /> Job Site Address: diSlo t.->r b{, ,_i- k. l l S c c.Q . <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes KNo <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: <br /> Name: Hc..r,Cock- �ow.c ..Tryk .`1_,C.- tee,- L1fJ C_ -; <br /> State License# j6 3oC6 y.� I Expiration Date: }-kc.r`.ti•.. .Ut'J. <br /> Phone: 6/a- civ -rF'[ (office) (cell) <br /> Mailing Address: I pt.( b., w,,x,Q e,1- - Cit : t o ZIP: cS i '3 <br /> Contact Person: L -, .-;( Applicant is: CContractor ,�/ Homeowner (Circle One) <br /> Email and/or Fax: anc, -h� �r lr"- oi,.C.0 ,\- <br /> PROPERTY OWNER INFORMATION: <br /> Name: IV. (NA 4 `i"..-.cc_. (Z.`..k.h` < <br /> Phone(day): qS a - y73- ;Yl Y1, / <br /> Address: ,INC 1�..«bbz; h". Fit S r c. City: Occ r ,...ttiZIP: Sc3`1 <br /> Email and/or Fax 4.2A- J <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) [Remodel 0 Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) 0 Repair 0 Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑Siding 0 Restoration 0 Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof 0 Fire Damage www.minnehahacreek.org <br /> Overall Project Description: it1r,,,4-i c b i i,(1,,cj , <br /> Estimated Construction Valuation of Project(excluding land) $ la/00000�, C <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 altemative <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 govemmental agencies <br /> required by law. If you refuse to supply the information,the application may not be issued. <br /> Applicant's Signature: am' `' <br /> ,-cyaol Date: I i <br /> Last Updated: 05-04-2009 <br />