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City of O�rono �h/ � � <br /> 1 ��� V <br /> . Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: �Ol/— 6C�J 37Z... <br /> /g,�,� � PO Box 66 � <br /> � � � <br /> ' Crystal Bay, MN 55323-0066 Date received: <br /> �,� �'' �4�' a, Street Address: Received by: �'/� � �� <br /> �'� ' 'q�� Gti�' `\ ' n, '�� 2750 Kelley Parkway Plan review fee: �7"3•8/ <br /> t�kESH��`'� �Y � Orono, MN 55356 �p/�— O437J y� <br /> Total Fee: <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: �j�� _�;��6� /"��Z��,,� /�,�;G��,( <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> /f yes,a special event permit is required with Police Department and City Counci/approval 60 days prior to the event. Shuttle bus service wil/be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permifted events will not 6e allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: �� �, � � " <br /> � i_�;;� l��ti �c C.�'v �c,�� �' vv✓ <br /> State License# ���-� Expiration Date: ZL. I "z <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes fhat were constructed prior fo 1978 <br /> Phone: `�S�-�t"1.5 _ �.0`�I (office) (cell) <br /> Mailing Address �3c 3s C ►z c�� � City: �;:�,����� ZIP: 5-s � — <br /> Contact Person: �~'�yy,� ��'-��;- .�,� o,,t ���, ,���, ,�,� Applicant is: rac / Homeowner (Circle One� <br /> Email and/ Fa 7�Z_—� � ' - ��G;S- <br /> PROPERTY OWNER INFORMATION: <br /> Name: 51f:�,�t + ��'�i-t �,:t�S��--' <br /> Phone (day): G1�,Z_��-�3--�ll 3 <br /> Address: �:>Z.S S , r.>i2 L„,., r�=.�,f City: G�L>.,�, ZIP: �5_��1� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) �2emodel ❑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.minnehahacreek.orq <br /> Overall Project Description: ��yLi:G�.E..� (�.%��t ; \� �-� <br /> \ \��-��'�1� 'c.r;��1 <br /> Estimated Construction Valuation of Project(excluding land) $ `2, Qt�� <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 t su I the information,the a lication ma not be issued. <br /> Applicant's Signature: ��� ' � Date: ���� �/ <br /> ��T� <br /> Last Updated: 03-01-2011 <br />