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�o City of Orono <br /> /►q :, , X877 <br /> çpi „ � Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> �0 MailiP0 Box 66 ng Address: <br /> Permit number: 6:770D /D” Z;10/421/--- <br /> Crystal Bay, MN 55323-0066 Date received: 04 7/.2,011) <br /> a ,.,3y•`,' <br /> A, Street Address: Received by: `74 <br /> 1�t OVA 2750 Kelley Parkway Plan review fee: <br /> -keski Orono, MN 55356 <br /> Total Fee: A079 <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: <br /> Job Site Address: /O$'7 Z- J v</i 41_2 Die <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/AP LICANT INFORMATION: <br /> Name: Pl--(c-.- I<,(4-lCE 6'A R-i2/.� <br /> State License# •Z 0-az Expiration Date: 3/ /0 <br /> Phone: 2- -33 el— 3oo 6, <z11 (office) 952_ --yo f-<3 8 o (", ,-.7,--,---,c_..,: (cell) <br /> Mailing Address: .:gq. f CDLc5-4-r /¢t/ . Cit : ZIP: <br /> Contact Person: -EL /.0/,e<z m4 ,- Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: y —yo(/ -/3S d f- <br /> PROPERTY OWNER INFORMATION: <br /> Name: Z(9 0/2/i- 4-4..L 61--.vnf <br /> Phone (day): 9S-a- =y ZCo _ 'lam 7 <br /> Address: io 3 o Gv/LC_UL,1 LJ J ��sC City: e=75,26-)ik2o ZIP: S-5-3,c-c:, <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) XRemodel ❑Water Damage <br /> ❑Window(s) ❑ Repair Minnehaha Creek Watershed District(MCWD) <br /> p ❑ Storm Damage 18202 Minnetonka Blvd <br /> El Siding El Restoration Deephaven, MN 55391 <br /> ❑ Other: (specify) Phone: 952-471-0590 <br /> ElRe-roof Fax: 952-471-0682 <br /> ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description:/•v�7-4 -e_,,,, ;; w,sr L7 6 )34s4(4,` w//E_ cLc2S <br /> Estimated Construction Valuation of Project(excluding land) $ ,/47 Ono �, <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 /> /Zq,e/rApplicant's Signature: iei �t Date: Qr <br /> Last Updated: 05-04-2009 <br />