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, <br /> . � <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> _ Mailing Address: Permit number: �Q ^ l� <br /> Oy O�O CrysBtal Bay, MN 55323-0066 Date received: �d—� � �� <br /> � <br /> '� � Received by: <br /> - Street Address: <br /> �,� �i� •"�` �ti 2750 Kelley Parkway Plan review fee: <br /> l 4� Orono, MN 55356 <br /> '�?rEsxo4' <br /> Total Fee: ��'7 � �C' <br /> Main: 952-249�600 Fax: 952-249-4616 www ci.orono.mn.us /�-J <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 INFORMATIO�V: <br /> Job Site Address: �Z2.� �,�'-�-t'� (',.;�. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,a special event permit is required with rolice Department and City Council approva160 days'ri�r t�the event. Shuttle bus service ll 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: C ►�l �C1='--c�t-� .c-��! N c� <br /> State License# �j 0' Expiration Date: a 3 a.._ <br /> Phone: 1-��' ���.- `�' � ��' office cell <br /> Mailing Address: 3 y u G /t+� � S Ci : j«�-5 i o� ZIP:�S�� <br /> Contact Person: � �5?72�-�t Applicant is: ontra / Homeowner �ci�cieo�el <br /> Email and/or Fax: ' /?S� ��►" �C� <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��w� h-tL.� b vt- � <br /> Phone(day): �� � �'7 I� I �7 ' „ l <br /> Address: �12� �� �� City: C�C=C�rJ c' ZIP: .�S�.�/ <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> �Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> �mdow(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑Siding ❑ Restoration ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek orq <br /> Overall Project Description• lN 5 fh�w �r1b��y ������Ny b��.'����5, i^'�tt,� ( N�"''G�.G S�v'c�Drfi u�a�r��p.►�. <br /> Estimated Construction Valuation of Project(excluding land) $i'�, c;c�U "� <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 altemative <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 Gassified 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 su I the information,the a lication ma not be issued. <br /> Applicant's Signature: � ��� Date: !���� �1�1 � <br /> Last Updated: 05-04-2009 <br />