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� � ' City of Orono <br /> Building Permit Applic�tion for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: o���-QU <br /> Og,��.O PO Box 66 <br /> � <br /> Crystal Bay, MN 55323-0066 Date received: � <br /> a �. Streei Address; Recelved by: <br /> �, G4� 275o Kelley Parkway Plan review fee: <br /> �q�.�,�og'� Orono, MN 55356 <br /> T0131 FB6: ���r � <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 epplications wi11 be returned. (P/ease p�int) <br /> GEPIERAL INFORMATION: �, �1 <br /> Job Site Address: 3°5 v �a S�J� �`_ <br /> Will this be a Parade of Hames, Remodelers Showcase Home or othar Dlsplay Home? Yes No <br /> If yres,a special eveni perm)t)s rsquired with Pa�ce Deparimant�nd Ciry Council approval 60 days pi1c�to tha evenr. Shuttle bus servi�ce will6e <br /> required unless applica�rt demonstrates au1licient onstte parking is available. Non-permhtee events will not be alfowed. <br /> CONTRACTOR/APPLICANT INFORMATIOId: <br /> Name: j�p 2 <br /> Statg License# Zp�,3��� - Expiration Date: � � / <br /> Lead Certification Number: /J�j'� �qOyQ� / Expiration Date: <br /> (�ar work on hom�s ihat were constructed prior tu 1978 <br /> Phane: �3-(����-y��� (office) Co rZ� `�f�'j--2.[�S� (Cell) <br /> Mailing Add�ess: /ZS'F36 � 4`2"� �-F� �ar/ City� 1,� �V'�,/ ZIP: 5;�3 U <br /> Contact Person: 7�,,,� p�,��-��,-�' Applicant is: ractor / Homeowner (C��eie0ne) <br /> Email and/or Fax: y�w� � �t{l rr�n • Nts1-� �G3- �33�-9�� <br /> PROPERTY OWNER INFORMATION: <br /> Name: {�aXey► N�A�S�v� <br /> Phone (day): (,��2- gro _ D�4S <br /> Address: 3550 s�c��e 2 CitY: (�rr�,n� ZIP: j j S�o <br /> Email and/or Fax }���Q�Se�,1 �°a�Cas(; �rle <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may requtre <br /> ❑ Door(s) ❑ R�model ❑Water Damage MCWD revfew&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑W)ndow(s} ❑Repeir ❑Storm Damags 18202 Minnetonka elvd <br /> ❑Siding ❑Restoration ❑Dther. (specify) Deephaven,MN 55391 <br /> Phone: 952-471•D590 <br /> [�Re-roof ❑ Fre Damage Fax: 952-471-0682 <br /> www,(pinnehahacreek.orq <br /> Overall Project Description: �e � o-� <br /> Estimeted Constructlon Valuation of Pro'ect(excluding Iand) S /5 00 5 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agr�es to provide all information required or�equested by th�Building oepartment; <br /> • CeRifies that tt�e 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 eware that upon failure to do so, the staff has no alCematNe <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 cfass'rfied by State law as eithe� private or <br /> confidentiai_ Private data is information which generally cannot be given to the public but can be givsn to [he subject ot the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of th� data. Our <br /> purpose and intended use of thia infurmation is to annuall pdate our records and records of other govemmental agencies <br /> re ulred b law. If au refuse to su the info on lication ma not be issued. <br /> Applicant's Signature: Date: � 5 <br /> Lasl Updated: 03-U1-2011 <br /> Z�Z:a6ed 9T9b6bZZS6:ol :tuo.�� Z�:SZ ZTOZ-SO-�Jfld <br />