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City of Orono <br /> • � Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: � <br /> .�0,�. PO Box 66 Permit number: ��/G-CC��� <br /> � s� � <br /> Crystal Bay, MN 55323-0066 Date received: /� <br /> ��'��� Received by: <br /> ,� k-�_�,� �, I Street Address: <br /> '�,�,L �� '>"� �ti 2750 Kelley Parkway Plan review fee: <br /> ykESKo4,'� Orono, MN 55356 ,�.� <br /> Total Fee: 9,7 -��--�; <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us / V <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: ,'� �O �.��,e��f-�� ��,`�f ,� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �.�o <br /> If yes, a specia!event permit is required with 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/APPLICANT INFORMATI �I: <br /> �� <br /> Name: ��.,.- ;�c� �--s�r��_��__ � � C. <br /> State License# �v�yy� g Expira ' n Date: 3 3/-�/�- <br /> Phone: ��,}_ �j� _ �,a�7� (office}—� 5��-yq�—�-a.<:.� (cell) <br /> Mailing Address: s��l� /�.-�� Cit : ,;,��,l�t-- ZIP: S'�S`�— <br /> Contact Person: i Applicant is: racto � / Homeowner (Circle One) <br /> Email and/or Fax: c�� �t�� f � �v.ts��f�<t„ 1 ,2r-��/�'� �� i Cr.--�-. <br /> PROPERTY OWNER INFORMATION: <br /> Name: � ,� �'�.��� � <br /> Phone (day): <br /> Address: /,�Q�' ���«��� o,`�f .�� City:G�r/.,z��4_ ZIP: S�,��j'/ <br /> Email and/or Fax <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 /> c.�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.orp <br /> Overall Project Description:;2�,�/Y� �. ...-�.._,. �� " � � � ���:,� �� <br /> Estimated Construction Valuation of Project(excluding land) $ �C��'�� <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 inf rmation,the a lication ma not be issued. <br /> ,/ �'-��/D <br /> Applicant's Signature: Date: <br /> , <br /> Last Updated: 05-04-2009 <br />