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� . �.��� <br /> - C�ty of Orono <br /> Buiiding Permit Applicatlon for internal Work <br /> ' (windows, doors� siding, re-roof, etc.) <br /> r AAailing Address: Permit number. �G�ll�e��17� <br /> O.¢0�O PO Box 66 <br /> Crystel Bay,MN 55323-006B Date recelved: J� / <br /> � � Streef Addresa: Recelved by: <br /> 2750 Kelley Parlcw�y Plen review tee: <br /> i��� Orona, MN 55356 <br /> Total Fee: �3� ��� <br /> Maln: 952-249-4600 Fax: 85Z-249�61B www.c�mn.us <br /> Thls spplication form must be completed in full and all required Informetion must be submlited. <br /> Incompla�te appllca ons will be reWrned. (Please print) <br /> GENERAL INFORMATION: C� � � <br /> Job Slte Addross: ` � <br /> WIII thls be a Perad�of Homes�Remodolers Showcase M e or other Olsplay Home7 Yss No <br /> Kyrs,a specie/event peimff/s requ►►ed wr�h Po►!ce DePertment and Clry Coundl approvel 80 deys prbr to the evenr, Shuttle bus 8eivice wpl be <br /> r@quir�d unlesa appllcant damor►sNates auilJclent en.sile pe�icing Is avaU�ble_ Mon�ermifted events wlll�t be allowed, <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name� /�'I i�G✓�5� om�, Sot� G��l�Bd� L�yC <br /> State�icense# � ;�0 D/Q a 7 7 _ Expiratlo� Date' �3,�31 �p�� <br /> lead Certification Number: Expirallon Date: <br /> (l�or w�o►k on homes that were conatrucbe�p�lor ro 1878 <br /> Phone; 7� 3��/� 7-q G q 6 (o�ce) 176 3-o1g0- l 3� � (Ce��) <br /> Mailing Address' (p S (�P-�.FIr` �`�' Clty: �t'�p ���t• ZIP: SS3(p Q` <br /> Contact Person: �� �,.dQ�G� Applicant is: on ctor / Homeowner �c�io a�.► <br /> Emall and/or Fax: '>63 — y a 7� g0o� .._._ <br /> PROPERTY OWNER INFORMATION:; ., <br /> Name: _(�o�� I.✓�� I i Q�..5 <br /> _ .: <br /> Phone(day): <br /> Adaress: -7 45 �,-,-�l�r�.i� /�"'• c�ry:LD�� ���'. ziP: <br /> Emall and/or Fax <br /> PROJECT INFORMATION: <br /> Typs of Projact: Any earth movement may require <br /> Q Door(s) ❑Remodel ❑Water Damage , MCwD rsvlew 8 permlls: <br /> Minnehahe Creek Watershed District(MCWD) <br /> ❑Window�s) [] Repeir ❑Starm Damage 18202 Minneto�ka Blvd <br /> Deephav�n,MN 55381 <br /> ❑Siding O Restoration ❑Other: (apecify) Phone: 952�71-0590 <br /> �Re-rooi ❑ Flre Damsge Fax: 852�171-0682 <br /> www.minriEhahy�,cLrp�k.or�c <br /> Overall Project Descrlptlon: <br /> Estfmated Constructlon Valuation of ProJect excluding 18nd) S _�,_.. <br /> APPLlCANT ACKNOWLEDGEMENT: <br /> Agrees to provide all informetbn raquired or requested by the Bullding Depertment; <br /> Certifies thet the i�'ormation eupplied is true and correct to It�B best of hlslher knowledge. The applicant recognizes tltet they <br /> are solely responalble t�or submitting a complete epplicatlon being aware thai upon hallure to do so, the steff has no alternative <br /> but W reJect it u�til ii is complete; <br /> Some or ell of the informaUon thet you are asked to provide an thls appllce6o� is classfied by State law as either prlvate or <br /> confldential. Privete data is inivrmatton whfch generally cannot be given to the publle but can be given to the subJect of the <br /> daCa. Confldentlal data is infortnadon which generelly cannot be given to elther the public or the subJect of the data_ Our <br /> purpose and Intended use of thls Infomtiativn is to annualty update our recards and records of other governmental agencles <br /> ulred b law. (f u refuse to su the informetlon the a licatlon ma not be issued. <br /> ApplicanYs Signeture: .�.-�'� Date: <br /> ,��,� V !( <br /> Leel Updated: 03-01-2011 <br />