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• . t <br /> ` City of Orono <br /> ' Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> � Mailrng Address: Permit number: Q� '��- � ,��J <br /> �,L,��� PO Box 66 <br /> � y:\ Q `� Crystal Bay, MN 55323-0066 Date received: /7�O�j <br /> fl_ <br /> �� i <br /> a ��4-�;` �, i StreetAddress: Received by: <br /> ��'�,n�� ° �� �ti� 2750 Kelley Parkway Plan review fee: <br /> �.rf�og,w Orono, MM55356 <br /> ESH� � <br /> — Total Fee: �j�—�D <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �L � <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: �z <br /> Job Site Address: �7�S C�o(�r�s �U;✓t� �60� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �D <br /> If�res, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service ill be <br />� required unless applicant demonstrates sufficrent on-site parking is available. Non-permitted events will not be allowed. � <br /> CONTRACTOR/APPLICANT NFOR ATI,ON• <br /> Name: rS� cl��V1�� Z �1'� cMS� <br /> State License# Expiration Date: <br /> Phone: 2, g . S�,755.7q efifi��) _ (� cell <br /> Mailing Address: (,{ � o� S��a Cit : S ---ZtP- —�fj <br /> Contact Person: b ,s�S Applicant is: Contr ctor / Homeowners �c r�ie o�e� <br /> Email and/or Fax: r�y�� �` , C ���P'��u:e- <br /> PROPERTY OWNER INF RMATION: <br /> Name: �� Q,�b� c��v�l�°� �a�r <br /> Phone (day): �/S:f�� !�?,v - � I �3 7 <br /> Address: �'7,�� (��, 1�1� ���I City: ��'�No ZIP: �S ,��J� <br /> Email and/or Fax <br /> i <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> 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 �ther: (specify) Phone: 952-471-0590 <br /> ❑ Re-roof �-- y�'�(`��� Fax: 952-471-0682 <br /> ❑ Fire Damage �� � www.minnehahacreek.orq <br /> Overall Project Description: �����:fe` <br /> c�� �� c..�r�� ��r= � �' C�e��c� �,���, � ��✓�.r �<�� IrS�,e� <br /> Estimated Construction Valuation of Project(excludi g 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. Ou� <br /> purpose and intended use o this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refus t su I the infor tion,the a lication ma not be issued. <br /> i <br /> i . f/ <br /> Applicant's Signature: V '' Date: �/�lp � <br /> r <br /> Las'.Update� 0�-04-20Q9 � <br />