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City of Orono
<br /> , Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: �� 8j
<br /> g,�,� PO Box 66
<br /> Permit number:
<br /> 0,^ O Crystal Bay, MN 55323-0066 Date received: f� � �
<br /> �
<br /> � � � � Received b
<br /> � ��'��4;;;;� s,�! Street Address: y�
<br /> �'.�, �� 4 � Gti 2750 Kelley Parkway Plan review e:
<br /> L�kESH04'� Orono, MN 55356
<br /> Total Fee. /„Q„1/ �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us {%O ��`"
<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: �l�n �A s�� �r.Q
<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 Police Department and City Council approval 60 days prior to the event. Shuttle bus servic wil e
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION: U' l
<br /> Name: �x�-EL_ C�rv s1� v L-ha�v LLC� �1��F r l E��N F,v
<br /> State License# 2 039 t 1 S� Expiration Date: 3 z� �a
<br /> Phone: ��� - �q 5 -qao3 (office) l,s i - 3 30� `��� (cell)
<br /> Mailing Address: 1`1-7 Z3 'Z-'z'1-� Y1v� � Cit : r3; L�►<F ZIP: SS�v
<br /> Contact Person: w��•��E }-��;,�,E.� Applicant is: ontrac or / Homeowner (Circle One)
<br /> Email and/or Fax: mL��,'.yia,�p f��,�\ Gov�r{'�,�c,�-:�,-� b S
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: _� -� �M�,n,c.;b �t��.U�w.
<br /> Phone (day): !� - �52- `�1�2 - ''? qq�1,. c.al t - (��z _ S�8 - q31�
<br /> Address: y't l,b �n�<;�.Q,� �.�. City: ZIP:
<br /> Email and/or Fax �bu��,,,,,,,, Q�,�}G�;,,�,, G�,,,,�
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> MCWD review 8�permits
<br /> ❑ Door(s) ❑ Remodel �Water Damage
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> �e]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) $ Q�,00c� • °b
<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 information, the a lication ma not be issued.
<br /> ApplicanYs Signature: _ Date: <<1 yl2�o�
<br /> LastUpdated: 05-04-2009
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