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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: Permit number:
<br /> /.¢,0,�. � PO Box 66
<br /> /O ,, O Crystal Bay, MN 55323-0066 Date received:
<br /> i M�.
<br /> �',� ���-_.� �, Street Address: Received by:
<br /> \'�,F, � ��� Gti 2750 Kelley Parkway Plan review fee:
<br /> \ , � Orono, MN 55356
<br /> 9kESHo4
<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:
<br /> Job Site Address: i�-i�`? ';'� � r �;�+ ^�- �>;�.-�(%�,
<br /> Will this be a Parade of Homes, Rem delers 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/AP�LICANT INFORMATION:
<br /> Name: -';� ��;�,�;,1.i„ 1�'. �*,�;7.
<br /> State License# �,;�, ;,����1 �-- Expiration Date: ����r ���� ��
<br /> Phone: -�-�1 35-v��S 7 office �'!�-3(� �-7�-�y �' cell
<br /> Mailing Address: ��,��5 �� C:l��az- /!���t��. City: r���.��lr..��i�S ZIP:
<br /> Contact Person: (�,�L, ('�S S,�,� Applicant is: : Contr�ctor� / Homeowner (Circle One)
<br /> • �__ ._-_._...:-
<br /> Email and/or Fax: � ��1�_t y �,_� �'�,-�aSSi�1t;i'L�'atl��t •t'�`7�z
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ������.�,,p �,;���, �-z�
<br /> Phone (day): ,'r,� __ y �� , , ,�5� .
<br /> Address: l�l 3 {�,��'ii,y/,r�' � }�',. City: ('�✓(,Y'J� ZIP: C� �j�
<br /> Email and/or Fax �r�.�:� �� t ���.�. . �r ��� ,.�,G„ . �_ �� -:_ :F��. ';-:�-�-�.
<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:
<br /> Estimated Construction Valuation of Project(excluding land) $ �;� `�4���, 75
<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 b law. If ou refuse to suppl the information,the application ma not be issued.
<br /> Applicant's Signature: � ,{��,���� Date: ��/ U ��%
<br /> -' /, �
<br /> Last Updated: 05-04-2009
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