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� ����.�f � <br /> ., . � ���' <br /> ` , � City of Orono <br /> � Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> r Mailing Address: Permit number: <br /> ��,�. PO Box 66 <br /> � �� � <br /> Crystal Bay, MN 55323-0066 Date received: <br /> �'�;=�� � Received by: <br /> a � -�, �. Street Address: <br /> �'�c, '° ''� �ti 2750 Kelley Parkway Plan review fee: <br /> �9kESH0�`'� Orono, MN 55356 <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 INFORMATI N:,, � , ,�. � _ � �� 1t� fj A �-- ��-: <br /> Job Site Address: ���' �a�( () `f �� �Y �?�i�� ���"'�\; �J,� �� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or o her 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 su�cient on-srte parking is available. Non-permitted events will not be allowed. <br /> Name:�CTOR/ P�CANT INFORMATION:, � !�' � I „' _� ����; lY �5� �1 /�� � ,/ <br /> 1 V lX 7 <br /> State License# `�G�� t:�(�O Expiration Date: � � I�� <br /> Phone: - � " �)C office cell <br /> MailingAddress: -� iY�Y� ('1�� ��� Cit :� L,f ZIP:� �' �', <br /> Contact Person: - b `�L` � " � Applicant is: ContractorJ / Homeowner (Circle One) <br /> Email and/or Fax: -" <br /> PROPERTY OWNER INFORM���Q : <br /> Name: � �i.�C �.0 <br /> Phone (day): __. � l <br /> Address: �" ��('C' Cit : �/�l`;'✓1(i ZIP:J�;`�l<�� � <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: � , Any earth movement may require <br /> ���V I(��� MCWD review&permits <br /> Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(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: <br /> Estimated Construction Valuation of Project(excluding land) $ ,�( (;, �,� � <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 su I the� formation,the a lication ma not be issued. <br /> � <br /> ApplicanYs Signature: ,�' , � � Date: /� c ZC��G1 <br /> �' � <br /> Last Updated: 05-04-2009 <br />