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, � k <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) ��`.��� <br /> Mailing Address: Permit number: � (��'J '�j `� 7� <br /> �,�,�. PO Box 66 <br /> 0 � Q Crystal Bay, MN 55323-0066 Date received: Q 2-(Q (,� <br /> a ���.p� <br /> i�� ���s� �, StreetAddress: Received by: <br /> ,r. <br /> �'�c, %� '° '�� ��� 2750 Kelley Parkway Plan reviewfee: <br /> t9kESH��`'� Orono, MN 55356 <br /> -- Total Fee: J {1 ` (�� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.u� / V p <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: ��}�� ���,�,� �7��. � <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 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 INFORp�IATION:n � <br /> Name: j-�e�(.n-�c,c�s -�E YYI��� '�i :l ..�i <br /> State License# �-1py y-3b�tF Expiration Date: 3 3l-lt5 <br /> �' Phone: ------� �S� ggg-SSS� (o�ce) (cell) <br /> Mailing Address: �,� � jr�m,n �'���,,;�• �•� �4 Cit : � ZIP: E�S <br /> Contact Person: �-j-.e�� Applicant is: ontrac o Homeowner (Circle One) <br /> Email and/or Fax: ��rn�n �� L,tJ�-�ti,c� , �r t- _-�f5a �?�� ��S<! <br /> PROPERTY OWNER INFOR ATION: <br /> Name: � � �� 'f' <br /> Phone (day): >�. %' � <br /> Address: ��;iY�� ' City: ZIP: <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 /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: �C �Y��;c;� �'_{�1��-..� <br /> Estimated Construction Valuation of Project(excluding land) $ �j (��, `�'-� <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 /> re uired b law. If ou refuse to su I the inforrjiation,th '� lication ma not be issued. <br /> /' �` / C-. <br /> ApplicanYs Signature: �;� `��� Date: �� ���j ��� <br /> r <br /> Last Updated: 05-04-2009 <br />