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• <br /> 12 <br /> City of Orono \v <br /> Building Permit Application for internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: 02 010- oo98o <br /> /�,011> PO Box 66 <br /> 0 4, 0 Crystal Bay, MN 55323-0066 Date received: 7- I L.- (O <br /> a - ;- a/ Street Address: Received by: �Q S <br /> �`�l I,.�� o`er' 2750 Kelley Parkway <br /> Plan review fee: <br /> ?tr�sHo Orono, MN 55356 <br /> if <br /> Total Fee: ff 03p32O .5 <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: l �-/� // <br /> Job Site Address: (07�' ,//lle�,/ Vita) di", i aft1ne, p/V .5"1-5-3,5-k <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yeso <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 <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# /,/� Expiration Date: <br /> Phone: <br /> A/7)1 <br /> (, / J J (office) (cell) <br /> Mailing Address: `�l City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (circle one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFO-MATI• <br /> Name: 0-0 vtelI ilk()S N(r-E-id <br /> Phone(day): .- - di/ <br /> Address: 10C—Cc £2/f OW / it, Pi-i .,City: Or`e,/c.' ZIP: 3 5-6 <br /> Email and/or Fax 0 11I C I - o(A <br /> I ' dp ✓nes' �i,�g ,etf <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel MCWD review&permits <br /> ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> ❑Siding ❑ Restoration <br /> ther: (specify) Phone: 952-471-0590 <br /> ❑Re-roof . Fax: 952-471-0682 <br /> ❑Fire Dama•e www.minneh-hacreek.r. <br /> Overall Project Description: t � j1X/ 1 . >�i��I�Jt t�ir 1,1 00 <br /> Estimated Construction Valuation of Project(excluding Ian• $ Jl 7 .S j!/t <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 a••lication ma not be issued. <br /> Applicant's Signature: Date: Of /d <br /> Last Updated: 05-04-2009 <br />