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' � � City of Orono <br /> Building Permit Application for Internal Work <br /> - (windows, doors, siding, re-roof, etc.) <br /> � <br /> Mailing Address: Permit number: <br /> �v 0,� �� PO Box 66 <br /> 'Q ;,` 0 `1 Crystal Bay, MN 55323-0066 Date received: <br /> �ili�a ����s-r;w. �,�,I StreetAddress: Received by: <br /> �'�n��+ '"���, ���'/ 2750 Kelley Parkway Plan review fee: <br /> `�gE�Ho�/ 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. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ��- , !1 �( <br /> Will this be a Parade of Homes, Remodele Showcase Home or other Display Home? ❑ Yes No <br /> lf yes, a specia/event permit is required with Police Department and City Counci/approval 60 days prior to the event. Shuttle bus service will be <br /> required unless appficant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �e , c� i'�rrS�,�,1� �� �� � � <br /> State License# �7 p"���7"� �G Expiration Date: 3 - 3 t - ZD f C+ i <br /> Phone: 6 S/ -2/6 •-�j 2 3�3 (office) � ,M � (cell) <br /> Mailing Address: " c t 4 � Cit : �!,` � ZIP: $�S C' Z <br /> Contact Person: r � � ` Applicant is� ontractor Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: `' <br /> Name: � c r b �` .}- O � 5 0•'� <br /> Phone (day): C i Z - ��q - �'j S� <br /> Address: 3ts � a ��_ �� 3� � e �-� CitY� � r O(� d ZIP� � �3 5 � <br /> Email and/or Fax ' <br /> � <br /> PROJECT INFORMATION: <br /> � <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) �1 Repair �Storm Damage �c � 18202 Minnetonka Blvd <br /> � ��`c� Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> �31eck w�-�� L—u�� Fax: 952-471-0682 <br /> Re-roof ❑ Fire Damage n e v.� 1'r ��S c S www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) � �5 GDU,o cl <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 information,the a lication ma not be issued. <br /> �' <br /> Applicant's Signature: �- Date: �"' 2�'j �- � ! <br /> Last Updated: 05-04-2009 <br />