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. � <br /> �s� � � <br /> City of Orono <br /> Building Permit Appl�catlon for Internal Work <br /> ' (window$, doors, siding, re-roof, etc.) <br /> Melling Address: permit numbe�_ O/ — � �7 <br /> O�.��O PO Box 66 <br /> Crysfel Bey,MN 55323-0066 Dete recelved: i <br /> Street Address: Recefved by, <br /> � a� 2750 Kelley Parkway Plan review f : <br /> ��� Orono,MN 55356 <br /> —'" Total Fee: / /„� �� <br /> Main: 852 249-4600 Fax: 952-249�616 www.ci,orono.mn.us (% <br /> This application fi�rm must be completed in full and aU requlred Informadon must be submltted. <br /> Incomplete appllcatlons will be retumed. (Please p�fnt) <br /> G�NERAI.INFORMATION: �� ���� _ <br /> Job Slte Address: <br /> Will thls b�a Parade oi Homes. Remodelers Showca Home or other Dlsplay Nome? Yes No <br /> !lyrs,a spedal a�ent pemu7 i8 required with PoIIce Departrnent ernl Chy Counal approva!60 days prior to the evant Shutde bus seMca will 68 <br /> requbed unless appllcant demonsnstes suf/kalent on,sire pa�kiny is availab/e. Non�ennlKed ev�ents will not be allowAd. <br /> CONTRACTOR/APPLIC T INFORMATION: <br /> Name: %l'Jr�G/157� I��OF.� S��/� f�A�1�U� LnC <br /> State License# 2 0 0�o a ,� Expiration Date: �3,/.,�//a�/,� � <br /> Lead Certification Number: Expiretion Date: <br /> (ror rvork on homes that wsra consbvc�pr�or ev 1878 � <br /> Phone� 76�—�/a 7" 9(v (o��) 76 3-a8o— /3� � {cell) <br /> Mailing Address: � S r-►.pr C� City: Q�le rpc��- 21P: �'S'3 6 q <br /> Contact Person: /�,ryn�J� �„dQ,s�.,� Applicant is: on ctor / Homeowner �ciroi.o�.� <br /> Email and/or Fax_ ')63 ... y �7— ypd! <br /> PROPERTY OWNER IN ORMATIQN: <br /> N�me: � (l L (:ro'¢-c�n <br /> Phone(day): <br /> Address: 1�a -'''�� �0� �� r• C�ty: �vey����. ZIP: <br /> Email end/or Fax � � <br /> PROJECT INFORMATION: <br /> Typs of ProJect: Any aarth movsment may requlre � <br /> []Door(s) ❑Remodel ❑Waber Damage MCWD revlew 8 p.Rnits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) []Repair ❑Storm Damege 18202 Minnetonka Blvd <br /> ❑Slding ❑Restoration ❑Other:(specify) Deepheven,MN 55391 <br /> Phone: 852-471-0580 <br /> �Re-roof ❑Ffre Demage Fax: 952-471-0682 <br /> www.minnehahar�rpe�k.ors� <br /> Overall Pro ect Descriptlon: <br /> Estlmated Construction Valuation of Project(excludln land s <br /> APPUCANT ACKNOWLEDGEMENT: <br /> Agrees to provide all informe�6on roqulred or requested by the 6uilding DepartmenC <br /> CeNfies that the irrfo►mation supplled Is vue and conect to the best of hls/her knowledge_ The applicant recognizes that they <br /> are solely responslble for subml�ing a complete application being aware that upvn Failure to do so, the stsff has no alternetive <br /> but to reJeet it urrhil it is oomplete; <br /> Soms or all of the ininnnetion thet you ere asked to provide on this eppl�aUon is dassfied by State law as either private or <br /> confidentlal. Prfvate dafa is inf�rmation whfch generally cannot be given to the publlc but can be given to the subject of the <br /> data. Confidentlal dats !s Intbrmation which generally cennot be glven Do either the publlc or the subject of the data. Our <br /> purpose and intended use of thls Inbrmativn is to annually update our recorrls and records of other gavemmental ege�cles <br /> re ulred b law. If u refuse to su I the Informatinn Ihe a (ica6on ma not be issued. <br /> ' ��� —r� <br /> Applicant's Signature: � C �--•�� Dete: � � <br /> Last Updabed: 03-01-2011 <br />