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City of Orono <br /> Building Permit Application <br /> Mailing Address: Permit number: <br /> O.¢,�,�.0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> ,� � � �� �, Street Address: Received by: <br /> '�,�, � �titi 2750 Kelley Parkway Plan review fee: <br /> L�kEsBof`ti'� Orono, MN 55356 <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: Q ,p� <br /> Job Site Address: "����� I.�u SI� f�/I� ON q ��3�tP <br /> Will this be a Parade of Homes, Remodelers Showcase Home or ot r Display Home? ❑Yes No <br /> /f yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service wi/!be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATIO�I:f <br /> Name: t <br /> Phone(day): -2 - ��- <br /> Address: � - Cit : (,,> ' ZIP: 5 <br /> Email and/or Fax " y � <br /> � <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8�permits <br /> 0 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 8 Restoration ❑Other: (specify) Phone: 952-471-0590 <br /> , Fax: 952-471-0682 <br /> Re-roof ❑Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: h�� -��, <br /> Estimated Construction Valuation of Proje t(excluding land) $ 2v00,0� <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 informatio is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to su ply the' f mation,the application may not be issued. <br /> ApplicanYs Signature: Date: 0� �� �U <br /> ��� Reset Form ,��,; � <br />