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t ,. Cek--/ .) <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: <br /> 14,O PO Box 66 Permit number: ,2U/6 —Qb w v\ Crystal Bay, MN 55323-0066 Date received: 3/Z//CD <br /> , ''`' Received by: <br /> a� 4fL2.3 <br /> J <br /> Street Address:2750 Kelley Parkway Plan review fee: <br /> Orono, MN 55356 <br /> Total Fee: <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: �j <br /> Job Site Address: /WOG/) y�A-,I2 "ee-eel ,�`i�f e . 1l'`/� ,]�, <br /> Will this be a Parade of Homes, Remodelers Showcase Home or otherc,D'tsplay Home? ❑ Yes l 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 INFORMATIO <br /> Name: -77„..d,teied'c{ 4--14-16i---5 `yx,..- <br /> State License# gel, 3,3 -7 Expiration Date: 3 / 3i /1 l <br /> Phone: /051- . - g-g. (office) (cell) <br /> Mailing Address: 7''O , �. x_,(G / City: (7i-eve ZIP: 553// <br /> Contact Person: �u„r,,fle, �(x� /J Applicant is: Contra for / Homeowner (circle One) <br /> Email and/or Fax: 7103 -,/j - .7 U <br /> PROPERTY OWNER INFORM ION: 4xe <br /> Name: ,5'72z,/--/ sGt-r cl_ <br /> Phone (day): - y 3 5�� � <br /> Address: /15'U w,c.<1 f "Ze " City: /On/ A�Ce ZIP: 55351 <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 ../KI.--- <br /> , Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> E Siding .Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> 'e-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: c `� <br /> Estimated Construction Valuation of Project(excl mg land) $ 7 bbU <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 t information,•the application may not be issued. <br /> Applicant's Signature: (Vail Date: / W;(7 .g4/6) <br /> Last Updated: 05-04-2009 <br />