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� �� <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> �f��dows, doors, siding, re-roof, etc.) <br /> — Mailing Address: <br /> c ��9 Permit number: <br /> � �v�,�`��\ J�P � 5 ��I"t PO Box 66 <br /> /j� �A� Crystal Bay, MN 55323-0066 Date received: <br /> 1� 1� <br /> 1��� ,n;"�',�'�• '.._ �.���fl������t Address: Received by: <br /> ��' � �' ���. ' `�' 2750 Kelley Parkway <br /> �' ','�'- �!� a ~� Plan reviewfee: <br /> t�y��f�,��grpZ`gr��� Orono, MN 55356 <br /> :�.IfESH�,-� <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. (P/ease print) <br /> GENERAL INFORMATION�� �O �� r t l /���� C <br /> Job Site Address: S -t' � Q � ,� �J <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 requi�ed 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: 9S��3yS • 4 � Y 7 <br /> Name: <br /> State �icense# THD At- Home Service, Inc, o di <br /> Phone: 2690 Cumberland Pkwy, Ste 300 (cell) <br /> Mailing Address: Atlanta, GA 30339-3913 ZIP: <br /> Contact Person: Lic # CR268257 Ph. 763/542-8826 lomeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INF MATION: <br /> Name: �0 h Q 0 n 0 S �-Q. <br /> Phone (day): QS'a �l'� 7 - S/y <br /> Address: Y e'Z 5 � o /'t � � Q �L �� c�t : /'') o ,►n d ZIP: 's S 3 L x <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 ❑ Storm Damage 18202 Minnetonka Blvd <br /> �Sidin Deephaven, MN 55391 <br /> � g ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> l Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www. innehahacreek.or <br /> Overall Project Description: � � � p /?') ,e 0 � b 0 Y�7 / n <br /> Estimated Construction Valuation of Project (excl ding land) $ � t�� Q 9 7 <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 annualty update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su pl the information, the a lication ma not be issued. <br /> ApplicanYs Signature: ��-� v � Date: l � �j [ � 7 <br /> Last Updated: OS-04-2009 <br />