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j , _ <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> � PO Box 66 <br /> � � Crystal Bay, MN 55323-0066 Date received: <br /> � �� 0 �I <br /> �a�� <br /> ,� 1 �,��-;;� �„ I Street Address: Received by: <br /> y „ _� <br /> �'� � G� 2750 Kelley Parkway Plan review fee: <br /> L�kE`sH�g'� Orono, MN 55356 <br /> ----. <br /> Total Fee: J C, / , )� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us / (P ( <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: � -��� ��z.,� . _ � �� ' �.i �-�+ �-� ►J V � v� . �V ����u ; G�c�. <br /> Will this be a Parade of omes, Remod ers Sh wcase Home or other Display Home? ❑ Yes No <br /> lf yes, a special event permit is required with Police Department and City Council approva!60 days prior to the event. Shuttle bus service will t�e <br /> required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INF MATION: r <br /> Name: � . � �v_�-f-l� S�So c� �(C <br /> State License# , � 3 �, Expiration Date: 'Z �,� -; p/ � <br /> Phone: � ' � office s ,,,�� � J cell <br /> Mailing Address: ` M h� l . Cit �_._____ ZIP: <br /> Contact Person: o. c r aU � z c� � Applicant is�Contractor.._y Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNE FORMATI : I <br /> Name: �,:�� �c� Yj-��„�j <br /> Phone (day): /� <br /> Address: � � �x�a �U'r v-2 City:C/V� �t�v ZIP� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door s MCWD review 8�permits <br /> ( ) ❑ 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) $ �/�j fj �� � ` <br /> �f�. <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Buitding Department; <br /> • Certifles 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 /> � <br /> � ✓� ��) <br /> - ApplicanYs Signature: �' Date: �� ��� U /C/ <br /> Last Updated: 05-04-2009 <br />