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Cit of Orono G�� �� <br /> Y 5 <br /> � •• Building Permit Application for Internal Work /�5� <br /> ` (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: d b!/-�O <br /> 4v 0,� PO Box 66 <br /> �--_� Crystal Bay, MN 55323-0066 Date received: �/ / <br /> ������ � <br /> (,� ���' ��;; s, I StreetAddress: Received by: <br /> �'�,n ���A,"�, ���' 2750 Kelley Parkway Plan review fee: <br /> L�s��o4w Orono, MN 55356 <br /> �ESH� <br /> '- Total Fee: g 3 �. 7 g <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 applications will be returned. (Please print) <br /> GENERAL INFORMATION: � � <br /> Job Site Address: '``75 �r'�.�� I�:� - � �- <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o <br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: %�� ��L r'�U ��-t-. <br /> State License# ,�U �, �� � �v Expiration Date: <br /> zC� i� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: �'��z� 2�j(� -- ��? (office) (cell) <br /> Mailing Address: ,��� <br /> �=7_`l —� ,�--��.�� �� , citY:I�.c,.1 L�l�� zIP: S�5��L <br /> Contact Person: �, �,� ����,� Applicant is: Contrac r / Homeowner (Circle One) <br /> Email and/or Fax: !�� ,�.(1 S�{ ( �1 �_�,z c;��1�-} , ��--� <br /> PROPERTY OWNER INFORMATION: <br /> Name: ;..5�;1�n � ��1 -���� <br /> Phone (day): �I'��r �f�7 3' 7�o � <br /> Address: f y �- 5� '�,��,� �, City: �t��:: -� p ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: � Any earth movement may require <br /> ❑ Door(s) Remodel ❑Water Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> www.min nehahacreek.orq <br /> Overall Project Description: ,.�,7�, b�,,.� y��,.:-} v, c. �vF.� �.r���, ,�-. Z — �c� �t:�,L, � <br /> Estimated Construction Valuation of Project(excluding land) $ "�� s� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the 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 aware that upon failure to do so, the staff has no alternative <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 classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to I the information,th� � lication ma not be issued. <br /> i' <br /> Applicant's Signature: � Date: �� ��� l 1 <br /> Last Updated: 03-01-2011 <br />