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ArRiC1���G�14/TUE 04; 28 AM Elder Jones Building FAX No, 952 854 4909 P, 002 <br /> �r <br /> � <br /> City of Orono <br /> Bui[ding Permit App[ication for Internal Work <br /> (windows, daors, siding, re4roofy etc.) <br /> Mailir7g A�ldress: � Z 7 <br /> �,�,�. PO Box 66 Permit number: - <br /> Yv CrystaE Bay, MN 55323-0066 Date received: —� <br /> � �; o <br /> "`�°,�'�,•- . Received by: <br /> a 4'�7�,,-;'' a, 5trgef Address= <br /> r�.� ,•.,,,�;,.- <br /> '� y�.�°ti�''rM� ti 2750 Kelley Parkway Plan review fe <br /> �R���S�oa��� Orono, MN 55356 � ���� <br /> Total Fee� . <br /> Main: 952-2�i9-G600 Fax: 952-249-4616 :vww, i. r n .mn.us <br /> � This application form rnust be complet�d in full and all required informatipn musT be submitted. <br /> Incomplate applications wiU be returned. (Please print) <br /> G�N�RAL lNFORMATION� � . � � �� � <br /> Job Site Address: <br /> Wil!this ba a I'arade of Womes, Remod�lers Showcase Home or other Dispfay Home? ❑ Yes No <br /> !f}�es,a special event permit is raquired witn Pollce Department and City Council approva160 days prJor to the event. Shuttla bus servlce wi!!be <br /> r�quired unless applicant demonstrates sufficienf on-site parking is avai/ab/e. Non�permitted events wi!!not be allow�ed. <br /> GONTRAC7d}�/APPLICANT INFORMATION: <br /> Name: 9'S.� 3y�•G q y,.7 <br /> State License# �e�la No�'t111a11d <br /> �hone: 15300 2Sth A.�e N. Ste J.00 c�ll <br /> Mailing Address: ____ P1�ni0uth,MN 55447 z�p- <br /> Contact Person: Lic#BC645090 Ph. 763/745�1400 {�meowner (Circle one) <br /> Email and/or Fax: <br /> PROPERTY OWtV�R 1 ORM TION: <br /> Name: ( C Q.C-�� � � <br /> Phone{day): '� C �D . 7 ,,/ / <br /> Address: 'Z /' 0 l..3 _ �� Q V City: �'��Q �Q C d ZIP: 'J�� s �+ <br /> T_ � <br /> Email and/or F2x <br /> PROJ�C7 INFORMATION: <br /> 7ype of ProJect Any earth movement may requlre <br /> MCWD review&permits <br /> ^oar(s) � ❑ Remodel ❑Water Damage <br /> Minnellaha Creek Watershed District(MCWO) <br /> !�1`4�lindow(s) � �,] Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑Siding ❑ Restoration [� Other: (specify) Phone: 952,471-0590 <br /> Fax: 952-471-p682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek,or � <br /> Overall Project Description: a �� �.,> >` d/� �� <br /> Estimated Construction Vaivation af Project(excluding fand $ <br /> J <br /> APPLiCANT ACKNOWLEDGEM�NT: <br /> - Agrees to provide all infnrmatipn required or requested by the�Uilding Department; <br /> . C�rtifces that the information suppli2d iS trUe and correct to the best of hiS/her�knowledge. The applicant r2GOg�iZ2S that they <br /> are Soleiy responsible for submittir�g a complete application being aware thaf upon failura to do so, fhe staff has no alternalivR <br /> but to reject it untif it is complete; <br /> • Some o�aU of the Information that you are asked tb provide on this application is classified by State law as either private or <br /> confidential. Private data is {nformatiof3 whiCh generally cannot be given tb the publiC bUt can be given to the SubjeCt Of thg <br /> data. Confidential tlata is infOrmation which generally cannOt be glven t0 9ither the public or the sUbject of the data. Our <br /> � purpose and intended use of this informafion is to annually update our records and records of other governmental agencies <br /> re uired b law. I� ou refuse to suppl the information,the a liC2tion ma not be issued. <br /> A [icanYs Si nature- � � Date: � � r �I� <br /> PP 9 � <br /> Lask Updated: 05-04-2009 <br />