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Jul, 18. 2011 10; 51AM NAVVIS SOLUTIONS No, 2364 P, 1 <br /> � <br /> City of Orono -� � ���il <br /> f I <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, r�-roof, etc.) <br /> MailingAddress: permit number: D//–��0� <br /> O�,Q,�.O PO Box 68 �'7 <br /> Crystal Bay, MN 55323-0066 Dale received: / � <br /> � � Slreef Address: Received by_ <br /> , 2750 Kelley Parkway Plan revfew fee: <br /> �y��e o�,��' Orono,MN 55356 � <br /> Tolal Fee; ���,�� <br /> Maln� 952-249�-0600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be complefed in full ahd all required Informatlon must be submitted. <br /> Ihcomplete appllcatlons wllf be returned. (P/ease print) <br /> GEN�RAL INFORMA710N: —1-- 1 <br /> Job 5ite Address: �� � �, S ..✓3 � �.v`G <br /> Will this be a Parade of Homes,Remodeler Showcase Home or other blsplay Home? Yes �No <br /> If yaa,a spec/al even(permlt!s requlred with Po/ice Depa�tment and City Council approva160 daya prior to the everlf. ShuP1/e bus servlc�e wlll be <br /> ieqoJied unless appllcant demons(retes suKclent on-site paricinq is available, Non-permilted events will not be ellowep! <br /> CONTFiACTOR I AI'PLICANT INFORMATION; <br /> Name� <br /> State License# Explration Date: <br /> Lead Ceriification Number: Expiration Date� <br /> (for work on homes that were constiucted prior to 19y8 <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Cont�actor / Homeowner (Clrcle One) <br /> Emafl andlor Fax� <br /> PROPERTY OWN�R INFOaMATION: <br /> Name: d,J �� I �i a w. ,f �l� �G f � <br /> Phona (day); p q (� <br /> Address� /.�G 9 �� S u S S�-Y 1` City: •��v1 tl e�an Isc�ZIP: S �.3 �.� <br /> Emafl and/or Fax � �j;� �@ ��P -J-� �-o � Ka^� C a r►1 4S,?- ��C - O N?3 <br /> PROJECT INFORMATION: <br /> Type of ProJect: Any earth movement may requlre <br /> ❑ Door(s) ❑Remodel ❑Waler Damage MCWO review 8�permits: <br /> Minnehaha Creek WaCershed Dlslrict(MCWD) <br /> 0 Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Slding ❑ Restoralion ❑Olher:(specify) Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> (�Re•roof ❑ Fire Damage Fax: 952-471-0662 <br /> www.mfnnehahacreek,orq <br /> Overall Pro'ect nescription: e i'oa W Sfwn �n se�z w� e-��, oe ('a ;� a4 <br /> Estimated Constructioh Valuation of Pr'oJect(excluding land) $ �bfl <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees lo provide all informalion required or requested by ihe Building Deparlment; <br /> � Certlfies that lhe informalion supplied is Irue and corrsct lo lhe hesl oF his/her knowledge. The appllcant recognizes thal they <br /> are solely responsible for submilling a complete applfcatlon being aware Ihat upon failure to do so,the staff has ho alternalive <br /> but to reject it until it is complete; <br /> • Some or all of the Information thal you are asked to provide on this application is classified by State law as ellher private or <br /> con�dential. Privala data is informalion which generally canhot be gfven to lhe public but can be given to Ihe subject of lhe <br /> data. Confidential dala Informallon whlch generally cannot be given lo eithar lha public or Ihe subjecl oF Che dala. Our <br /> purpose and inlended us of Ihis informa ion is annually update our records and records of other governmental agencies <br /> re uired b law. If ref e I th ' for all n the a licalion ma not be issued, <br /> Applicant's Signature; , (� Date: 7 � $ �� <br /> Lasl Updaled: 03-01-2011 <br />