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�J � �� <br /> � . <br /> City of Orono <br /> Bullding Permit Appllcation for Internal Work <br /> ' (windows� doors, slding, re{oof, etc.) <br /> Mailing Addr�ss: Pennit number_ ��`�— (' � <br /> O.¢��O PO Box 86 <br /> Crystal Bay, MN 55323-0066 Date rsceived: �O� / <br /> Streef Addies,s Received by: <br /> � � 2750 ICelfey Parkw�Y Plen reviaw fee: <br /> ��� Orono,MN 55356 <br /> Tatal Fee: ��p���S <br /> AAaln: 952 249-4600 F�x: 952-249-4816 ��.Q,rono.mn.us <br /> This application form must be completed in full and all required Informatlon must be submitted. <br /> Incompl�te application�will be retu��ed. P/ease print) <br /> GENERAL INFORMATION. �/-� �� � G��� <br /> Job Slte Address: V <br /> WIII thls be a Psrade oi Homes� Remodelers Sh se Home o�other Dlsplay Home? Yes NQ <br /> If yss,a speci�/event permit/8 reqWred wlth Pallce Deperh►�enf end Ci�y Coundl approval 60 days prior to the av�ent. ShufNe Du8 BeMce wNl be <br /> requlrs0 unlesa applic�rtf demonabales sufllclent on•site parkirig i8 aveilabfe. Non-perm![ted events will not be allowed. <br /> CONTRACTOR/APP�ICANT INFORMATiON: <br /> Name: %�'1:(�W�b7- �oOF�� ����� l�►�1�P� ,L,�C <br /> Stete Licens�# ;.Q p/p a 7 7 Expiration Date: ��/3/,/� f��� <br /> Lead Certification Number: Expiration Date: <br /> (Ror w��on homes that wens consbuc�prlor tv 19f8 <br /> Phone: 76.3- �/a 7-�!6q� co��� ?6 3--�So— 13� � c����� <br /> Mailing Address: (p� � C�- Clty: Q��' �c��- ZIP: 3 (p�{ <br /> Contact Person: �p.yn.��„�Qr,SG•� Appllcant is_ on ctor / Homeowner (Clrela dns) <br /> Email and/or Fax: '�63 -. �I �7= y0 / <br /> PROPERTY OWNER INFORMATION: <br /> Name: �1(;� Q�(�it_?'� <br /> Phone(day): <br /> Address� CJ' ��f-� ��. i� �G� l�/� City: �.�r7�i Gd/��: ZIP: <br /> Emall andlor Fax <br /> PR4JECT INFORMATION: <br /> Typo of ProJect: My QaRh movement may�qutro ���� <br /> ❑Door(s) ❑Remodel ❑Wete�Damage M�0�vlsw�permlis: <br /> Minnehaha Creek W�tershed Dlstrlct(MCWD) <br /> ❑Wlndow(s) ❑Repeir ❑ Stnrm Damage 18202 Minnetonka Blvd <br /> ❑Sidio Oeephaven,MN 55391 <br /> g ❑Restoration ❑Other�(specify) Phone; 952�71-0580 <br /> (�R�roof ❑ Flre Damage Fax: 852-471-0B82 <br /> www.rnlnr�el�ah�CreQk;Q„rc�. <br /> Overall Project Descrlptlon: , � <br /> Estlmated Conatru�tlon Valuatlo�of Project(excluding land) S � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agraes to provlde all informatlon requlred or requested by the Building Department; <br /> Certifies that the Infonnation supplled Is We and corract lo the besc of his/her knowledge. The applicant reCognizes that ihey <br /> ere solely responsible for submilting e compiete application being awsre thet upon f�ilure to do so, the steff hes no alternative <br /> but to reJect It untfl it is complete; <br /> Some or all of the informadon that you ere asked to provide on thls applica6on is dasslfled by Stete lew as either private or <br /> confldentlal. Prvvate data is InfortnaGon which generelly cannot be giv�en to the publlc but can be given to the subJect of the <br /> data. Confidendal d�ta Is Informadon which 9enerally cannot be giv�n to elther the public o�the subJect of the date. Our <br /> purpose and intended use of this informetlon ie tr� annually update our records and records o(other govemmental agencies <br /> r uired b law. If u refuse ro su the information the a Ilcation ma not be issued. <br /> APPlicant's Slgneture: �'"`'�'�c"'��L'�� '. Daie' ���� l� <br /> 1861 Updeted: 03-01-2011 <br />