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City of Orono Oa%-. <br /> - r <br /> Building Permit Application for Internal Work r ' <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: <br /> � <br /> 0� PO Box 66 Permit number: /p—ldd$',1 <br /> (- --‘ -- a Crystal Bay, MN 55323-0066 Date received: 7 '1 o20/O <br /> t i <br /> ' s. Street Address: Received by: <br /> �i; vt . G~ 2750 Kelley Parkway Plan review fee: <br /> sxo4` Orono, MN 55356 p <br /> Total Feer / <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 INFORMATIQN: <br /> Job Site Address: - Def �j-- . Cji--cimU <br /> will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? >l Yes1 j0 <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: "' ! ‘1-\1 "" C.CItclr_alCr. <br /> State License# �_ i <br /> - l .. Expiration Date: _3 <br /> Phone: <br /> C, _1_j1--;_I7C.p.3 (office) (cell) <br /> Mailing Address: 1... yQ ((..)-Ste'{12, pr- City:LOnr-fy\l ZIP: SS7-Sf*--7 <br /> 1C�i <br /> Contact Person: ff55Applicant is: Contractor / Homeowner {Circle One) <br /> Email and/or Fax: '\,-or-lvio AmS r>-r...6 9rndi I,Cry <br /> PROPERTY OWNER INFORMATION: <br /> Name: (' —r )1. <br /> Phone (day): <br /> -.AL at,, <br /> Address: j ab' m City: f-, ZIP:5-3 <br /> Email andlor Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑Door(s) iS*Remodel ❑Water Damage <br /> sMinnehaha Creek Watershed District(MCWD) <br /> 0 Window <br /> ( ) 0 Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ,S+.:--ding ❑ Restoration 5a Other: (specify) Phone: 952-471-0590 <br /> ❑ Re-roof ❑ Fire Dama a Fax: 952-471-0682 <br /> 9 www.minnehahacreek.oro <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ .'71 (lc' <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 /> ik <br /> Applicant's Signature: ,,4101 Date: 7/1 G///G <br /> Last Updated: 05-04-2009 <br /> Z.d 6L99-90t-Z96 NOILOf LSN00 2:13Al2 N021 e99:1.6 01. 171. In(' <br />