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12/27/2016 11:25 7637532595 STOP y;l , � ( �` i , PAGE 01/01
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<br /> Cit of Orono ,V q��� °��"� ° �� �����i� � �
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<br /> Building Permit Application for Internal Work
<br /> windows, doo�s, sOding, re-roof, etc.)
<br /> _ � Mailin Address� ' ;'
<br /> � �~ PO Box 66 ,,. ;;�?�;,��'!.
<br /> � � F'ennit�lu,'ttrb�r �'
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<br /> � F!�: :
<br /> � � Crystal Bay, MN 55323-006B �,batn Cqc�5lv.ed.:. . �:.:.. . ���:.
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<br /> ,.,�, �, Sfreef/lddress: I�eCelVed by � �
<br /> � � � . 2750 Kelle Parlcwa � � ,, "'
<br /> Y Y I�I�n PgVi�Vv.f��, , ' ' ,�
<br /> ��fe Orono, MN 55356 ` ���
<br /> Tatal Feec.. ,�/�
<br /> , . ..,�... �' „
<br /> Main: 952-249,4600 Fax; 952-249-4616 w�nn�v.ci.orono_mn.�c ,. l;"'-��..
<br /> .
<br /> This application form must be complel'ed in full and all required information must be submitted.
<br /> Incomplete applfcatlons will be�eturned. (P/oas0 print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: � �,5� ������'�r���n�► S�" . Ca(b� . r'r��
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Dispfay Home? Yes o
<br /> If yes,a speclal evenl parmif i9 repuired with I'olice I�epertment and Clty Councll approva160 days prla fo the av�nf. Shuttlo bus serv/cs wlll be
<br /> requlred unless appllcanf demonstretes su�cient on-site perking is avAilAble. Non•permifted events wlll not be allowod.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: _�r_v��c�¢ I��S ).� 7ro��1wr+�a�J
<br /> Slate License# 7 03��3'� � Expiratfon Date: __3�31- � 1
<br /> Phone: - o'Ffice , - cell
<br /> Mailing Add�ess: S i ��� Ci ZIP: 3
<br /> Contact Person; �'`�art,l� ��er���,,�- Applfcant fs� ontracto / omeowner �circre one�
<br /> Email and/qr Fax: _(YvaR,l�6� �h,p,� „c�,,n �ia.,� -�U,,3?�'SL,�.�y�-,S'
<br /> IPROPERTY OWNER I FORMATION:
<br /> Name; �" �m ��� n I�� i
<br /> Phone(day): _ _
<br /> Address: '�,'Z,7�� � ���� ��g�_Z,Q,, Ci�y: ,{�v�Javy�) Zlp:
<br /> �mail and/or Fax
<br /> PROJECT INFORMATION;
<br /> Type of Pro�ct: Any earth movement may require
<br /> MCWD reviaw&permits
<br /> i 0 Door(s) ❑Remodel ❑Water Damage
<br /> Minnehaha Creek Wate�shed Dlstrlct(MCWD)
<br /> ❑Wlndow(s) [] Repair ❑Storm Damage 18202 Mlnnetonka Blvd
<br /> ,,,_/ Deephaven,MN 55391
<br /> ❑Siding �Restoratlon ❑Other:(specity) Phone; 952-�471-0590
<br /> Fsx: 952-471,0682
<br /> ❑Re-roof ��re Damage wuvw.minnohaha�[oek.o[a
<br /> Overall Pro ect Descroptlon: '
<br /> Estimated Construction Val tion of Project(excluding land) $
<br /> APPLICANT ACKNOWLE EMENT:
<br /> • Agrees to provide all information required or requested by the Bullding Depertment;
<br /> • Certifies that the Information supplied is t�uo and co�r@ct to the best of his/her knowledge. The appllcant recognlzes lhat they
<br /> I are solely responsible for submitting a complcto application being aware that upon fallure to do so, the staff has no alternaGve
<br /> but to�eJect it until it is completa;
<br /> I • Somo or all of ihe InTor tlon that you are asked to provide on this application is classlFled by State law es elther private or
<br /> confldential. I�rivate da is information whlch generally cannot be given to the public but can be givvn to the subject oi the
<br /> i data. Confidential data I Iniormation which generally cannot be given to elthe�the publlc or the subject of the data. Our
<br /> I purpose and Intended uso of this information is to annuelly update our records and records of other governmental agencies
<br /> re uired b law. If ou reiuse to su ly the infarmation, the a lication ma not bc Issuod.
<br /> nppllcant's Signature: ����c C Dato: ��_� ">_ LL
<br /> l.est Updeted; 0�04-2008
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