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Nov-23-2011 08:35am From-CITY OF f tONO +g522494616 T-295 P.002/002 F-865 <br /> ♦1• r/ LL/ bV��l •.... v� .i '__'_ __"" _ <br /> � " � " <br /> City of Orono <br /> 6uilding Permifi Application �For Internal W ark <br /> (windows, doors� siding, re-roof, �tc.) <br /> MailJngAddress: Permlt number. O�L�� �� �� <br /> PO Box 66 <br /> O�"�'�a Crystai Bay,MN 55323-0066 Qate received_ � ��"` � <br /> Received by: <br /> � '"•T StreetAddress_ <br /> '� 275o Kelley Parkway Plan reviewf6e: <br /> ��'�;� Orono, MN 55356 / r� � (� <br /> ���'� a�' Total Fee: p� � �S <br /> Main_ 952-249-46Q0 Fax: 952-249-�1616 wvvyr,_cl.orono_mn_us <br /> Thls application form must be complated in full and all required information mu5t be submitted. <br /> Incomplete appliaatlons will be returned. (P/ease prirJtJ <br /> GENERAL INFORMATION:I�0 0 fa�Q C �L ,�0 l� 7� O <br /> Job Sito Address: � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display HQme? Yes No <br /> • lFyres,e speclsl evant permit is roquliBd wifh Po/fce DepcR1»ant and Gry Cou»c/f epprovs/60 dsys D!ioi lo�he evsl�I. Shutde Dus sarvres will be <br /> /gp�i/ed 4Aless eppficant d6mo/rSflBtes�u�ficlonf on�lte parkin9�s avsilable. Non-perml�d aver,ts�wll!��ot be apowed- <br /> CONTRACTOR/APPLICANT INFORMATION= J 0�II <br /> Name: cs ��= ��� <br /> State License# cell <br /> Phone: � n n � � � /' � � � 100 " ZIP: <br /> Mai�(ng Address: �C � t - <br /> Contact Person: iomeowner �corc�oone� <br /> � , / �45-1.400 <br /> Emaif and/or Fax: —' <br /> pROP�Rn OWNER INI <br /> Name: <br /> Phone(day): � Citv� � Y Z Q�� z�P: 5�'3 q/_ <br /> Address: _� - <br /> Email and/or Fax ; CEder-Jones Building Permit Service, Itt <br /> PROJ�C7 IN�ORMA1 :; �120 E. $O t h St <br /> -�� , Any earth rnov�sment may requ7re <br /> Type of Projecr. ���C19'i��fl� 5��; ���+� ����� MCWD review&permlts <br /> ❑Gooi(s) � � Minnehaha Creek Wate�shed Distrid(MCWp) � <br /> W�ndow s 182�2 Minnetonka Blvd <br /> � � Deephav2n,MN 55391 <br /> Q Slding ❑ Rastoratlon � U Other:�Sp6Gry) PhOf1e: 952-471-0590 <br /> Fax_ 952�7'I-0682 <br /> ❑Re-roof � � Flre Damags� <br /> www"minne a ac e c.o <br /> overell Pro ect Description: W I n d a GJ �'� 0 Gt M/�,_S !� ��'/s ���4 �p��'�t - <br /> Estimated Constructlan Valustion o� Project(excludln� land) $ � 'Q G � <br /> APPLICANT ACKNbWLEDGEME JT: <br /> . Agrees to provlde all information requirea or�equested by the Bullding Department: <br /> . Cartifles that the iriforrs+atlon supp��gd is true and correct to the best uf hislher knowledge. rhe applicant recognizes that ihey <br /> are solely responsible fof submilCing a aompletn applicatfon being aware that upon failure to do sa,the staff has no altemat�ve <br /> but to rejed'R untfl�t is cemplete; <br /> . Some or all of tne Ittformatiorl that you are askad to provida on this application is classified by State law as erther pr�vate or <br /> confidentlal. Pflvate ddta is inform8tlon whlch generally cannot be given to the public qut can be given to the subjea of the <br /> d8ta. Cprlfidential d2tz f9 Informatiotl which genarally Cannet be given to blthef She public or the Subjeot of the data. Ou� <br /> Per��ad bn awtc�iapu�efu ef to su'�)r hA ntormation thele uDcat�o�ma narob�a3su dcordS of othef gOvernmental agenCies <br /> Appllcant's Signature: � <br /> /� Date: _ (�l '�` l / <br /> I acf I InnAted: 05-04-2000 <br />