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<br /> City of Orono
<br /> Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> �-__-� Mailing Address:
<br /> ///�/ � PO Box 66 Permit number: p2(J�/�bd,.�
<br /> o� � Crystal Bay, MN 553Z3-0066 Date receivetl: 7 /�
<br /> I' q��` O ,II .
<br /> iM .
<br /> ;��\.� �, �;�,��A;_ �./� SfreetAdd�ess: Recelved by: �
<br /> �s2, ° � G� � 2750 Kelley Parkway Pian review fee: �
<br /> '�Rk'� ¢� Orona, MN 55356 ,
<br /> .....�sI�O,.,
<br /> '-�-- � Total Fee: ���. �,��"
<br /> Main: 952-249�600 Fax; 952-249-4616 www.ci.Qrono.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:
<br /> Job Site Address: ' y�� � '�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No
<br /> !f yes, a specis!event peimit is required wr(h Po�ice Depa�men!and Crty Counc�7 approval 60 days prior to!he evenl. Shuale ovs se�vice will bo
<br /> required unlesS appliCenf demonslr�les suKicient on-S�fe perking�s available. Non-permitled even(s viill nol be allowed•
<br /> CONTRAC70R!APPLICANT INFORMATION:
<br /> Name: m� � a,� $� ��
<br /> State License # Expiration Date: Q,3 ' a0
<br /> Lead Ceriificatipn Number: ��T�Jc9��.�� Expiration Date: (p �OIS
<br /> (for work on homes thaf were cor+structed prior to 1978 � --- �—
<br /> Phone: �5���7(�0,3 (office) i�/a, (ce�i)
<br /> MailingAddress: �� �y• ,�j City� 'b�pm% , h ZIP; 3
<br /> Contact Person: �Jn��� Applicant is: Contractor Homcowner �c�r��e o���
<br /> Email and/or Fax: .���� J�,�,,y,,.�onsf,.�c�,�r �.�r i cq�. �sa- qa!,-,.,�!_�y
<br /> PROPER7Y OWNER INFORMATION:
<br /> Name: --��Pn�UD`�'��L�'2/�' „.. . . . .
<br /> ac���
<br /> Phone (day); 9�� �1��-/�l3(0
<br /> Address; C�o7(�S j�Dl2'S�'LC� DY� City: �Oc�n� zIP: �"'j3C��
<br /> Email andlor Fax ��
<br /> PROJECT INFORMATION:
<br /> 7ype of Project: , Any earth rnovement may require �
<br /> Door s Remodel MCWD review&permits�
<br /> ❑ O ❑ ❑Waler Damage Minnehaha Creek Watershed District(MCWD)
<br /> ❑Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd
<br /> �ee haven, MN 55391 �
<br /> ❑Siding ❑ ReStora(ion ❑Other: {specify) Phone: 952-Q�1-0590
<br /> �Re-roof ���j?qf f ❑ Fire Damage , Fax: 952-471-OfiFt2 �
<br /> � www.rninriehah�cr_ e�,_k.,c,�„,rg i
<br /> Overall Project Description; y�Q
<br /> — -- --... . I
<br /> Estimated ConstrucSion Valuation ef Project (excluding lan,d) $ Jd���} ,., ,,_^__
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> Agrees to provide all information required or requested by the Building Department;
<br /> � Certifies thal the information supplied is [rue and correct to Ihe best of hislher knowledge, The applicant reCogniZes that they
<br /> are Solely responsible for submitting a complete appliCation beinq awara that upon failure to do so, the staff has no alternativo �
<br /> but t0 reject it until it is complete;
<br /> � Some or all oi the infOrmation that you are asked to provide on this application is classified by State law as either pri�ate or
<br /> confidential. Private data is information whiCh ggnerally eannot be given to the public but can be yivrn lo the subject oi the
<br /> data. Confidential daia is information which generally Cannot be given to eilher the public or the subject of the data. Ou�
<br /> purpose and intended use of thls IniOrmation is to annually update our records and records of otMer governmenta( agencies
<br /> re uired b law. If ou refuse fo su� I the information, lhe a lica�ion ma not be issued.
<br /> Applican�'s Signature: Date: �'/���
<br /> Las�UpOatetl: 03-01-2�11
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