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0.7/06/�011 13:09 5156616336 PAGE 01/01 <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 <br />