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_ . 4. ..56,0e <br /> Q))344° City of Orono <br /> Building Permit Application for Internal Work ,/ _ <br /> (windows, doors, siding, re-roof, etc.) A.3,.6-z) <br /> Mailing Address: Permit number: °70/0 -00023 7 <br /> 04, PO Box 66 <br /> 0 Q Crystal Bay, MN 55323-0066 Date received: 'f-/q-%- /0 <br /> s e.' <br /> 4 l., Street Address: Received by: <br /> �� <br /> ��t �,o4;171G* 2750 Kelley Parkway Plan review fee: o20/D-OGa 3!o <br /> 9tfESHo4�' 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: <br /> Job Site Address: �3S w�)J --Itit:f/ &-•-1. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? fI Yes [-'1 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 INFORMATION: <br /> Name: 'c._ 77--- I S e.-r <br /> State License# Expiration Date: _ <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Sc¢T Hai sai Applicant is: Contractor /c1omeowne'r (circle one) <br /> Email and/or Fax: Sc/yf- Verci).47 — e(ec7 - c"1 <br /> PROPERTY OWNER INFORMATION: <br /> Name: fcaT T f/S-rS14 <br /> Phone (day): 9S - SC 7- Ar 0( <br /> Address: 8"35 k.v1ici,iq-v-p/ i--r.. City: 0'a.-re ZIP: SSJr./ <br /> Email and/or Fax Sc,^7r(.ti' VerrJa-iT- e/ecT,'I- - Cl r Ar- /-e c,a7T4 ( ^-t S--r. cs . <br /> PROJECT INFORMATION: <br /> Type of Project: I Any earth movement may require <br /> ❑ Door(s) MCWD review&permits <br /> Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> El Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> CI Siding Deephaven, MN 55391 <br /> g ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re roof <br /> ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: -�,`-risk ct pq77/t(,- re,..10(74/a cc,c.re-i cit-- <br /> Estimated <br /> _1 TEstimated Construction Valuation of Project(excluding land) $ A_S'ioOD ''-:- <br /> APPLICANT <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 /> Applicant's Signature: l Date: `7ui 7itd <br /> Last Updated: 05-04-2009 <br />