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� � City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: �D/Q— DiDZ7`� <br /> 4,i+�.j� PO Box 66 <br /> Q `\ Q Crystal Bay, MN 55323-0066 Date received: `�,Z 7��� <br /> i� �s,.�..a <br /> � ����.�;e�':>��. a. � Street Address: Received by: ,�j <br /> �'�n '�� ���� �ti�' � 2750 Kelley Parkway Plan review fee: <br /> ��kESH�4'� Orono, MN 55356 � <br /> Total Fee: �f a �''� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � / 7(/�.J <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: �bO �� ,����, <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers owcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a special event permit is required wrth Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR 1 APPLICANT INFORMATION: , �7-- <br /> Name: :__�:- �^ �'> �1 I Y�1� `t'� ,1—hL . <br /> State License# 2-G� 7 3 �`l� Expiration Date: ,y� 2;.� / <br />� Phone: 3 ��1� office �uiZ- 3 "� �- � (-6� cell <br /> Mai ling A d dress: Z G) 0-�� � Cit : j� �Ic,,.-� ZIP: S� �,� <br /> Contact Person: , j,..L. Applicant is: nt / Homeowner (Circle One) <br /> Email and/or Fax: e_;S o��,'r,,� e v� ,n.;��..�Yc�����e.cc<r. <br /> PROPERTY OWNER INFORMATION: }� <br /> Name: __ I����V\ � �� »�,S <br /> Phone (day): z-- ���Z <br /> Address: Z i�l (�-��-�',h�;� >� City��`ic^ <;--�-� ZIP� 5�3/� <br /> Email and/or Fax - <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel MCWD review&permits <br /> ❑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) -r f Phone: 952-471-0590 <br /> ❑ Re-roof � �'y,y� ��„c� � (�th�'� Fax: 952-471-0682 <br /> ❑ Fire Damage 1 www.minnehahacreek.orq <br /> Overall Project Description: �°� Z `r' ��` �e�� �N <br /> Estimated Construction Valuation of roject excluding land) $ Z �''JO ►?.�..'v4✓L ►�}✓140 <br /> � <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 u are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is i rmation which generall nnot be given to the public but can be given to the subject of the <br /> data. Confidential data is � formation hich gener y c not be given to either the public or the subject of the data. Our <br /> purpose and intended use f this i rmation is t a ally update our records and records of other governmental agencies <br /> re uired b law. If ou refu e to I the infor � n,the a lication ma not be issued. <br />� <br /> ApplicanYs Signature: Date: _�7�G�� <br /> Last Updated: 05-04-2009 <br />