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" ( � (;'� ����� � � <br /> . �;�- `= <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> �____� Mailing Address: <br /> �,�,�\ PO Box 66 Permit number: /!�- (.Y�/S�� <br /> � 1 Crystal Bay, MN 55323-0066 Date received: �/�J /D <br /> ' _ ��� �\� <br /> �� �� ` a,I� Street Address: Received by: _ <br /> �y"-�� <br /> ` Gti�' 2750 Kelley Parkway Plan review fee: . ` � � � , <br /> \�kESFi04'� Orono, MN 55356 �"�`' <br /> _ _- "�" Total Fee: p���, �� <br /> u��,.�`� , <br /> Main: 952-249-4600 Fax: 952-249-4616 www ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. (`' . ;1 r � <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: z�s��'� c��,, �>� „�,,�� ,�,�dv� w . Qi�'��v<; <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes 0 No <br /> If yes, a special 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 su�cient on-site parking is available. lVon-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: w�t�� �,� 5;;� �FT ' �.<,�� LL <br /> State License# Z o 3 9 0 9 0 � Expiration Date: 3 3� �2 oi o <br /> Phone: t�,2 8s a � yooZ (o�ce) Z�/L2 8�o � �oaZ (cell) <br /> Mailing Address: 3o�,S �i�nr�v��nn ,�.� � S. Ci : l� ZIP: s,f' J <br /> Contact Person: j� ` C,�z�.� Applicant is: ontracto / Homeowner (Circle One) <br /> Email and/or Fax: !�,c,�z � �c,;�P-��.-� s�2 s �r= �o ry,�S - �a � <br /> PROPERTY OWNER INFORMATION: <br /> Name: 6�o.v � 1�.2�sn�v� ���2.��✓ <br /> Phone (day): 9�z yS7 � 9 y� L/ <br /> Address: Z�9S C�✓�s�,r��. D2�v�' (�/ City� a2aNb ZIP� S�-3sCo <br /> Email and/or Fax A�N c- P�P��GSsyN c� tr/r��s''/L . o.-L. <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 /> ❑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 orq <br /> Overall Project Description: �mo,o�-` ��c i5»�✓7r r3.1,'zf -S� ,�-7t�/,r�,2 �Lr/� � �o S7�uC'Izi�� iNv¢�v`�a . <br /> Estimated Construction Valuation of Project(excluding land) $ � , doa <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 altemative <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 Gassified 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 information,the a lication ma not be issued. <br /> ApplicanYs Signature: '�"„G�-C� � Date: 3 �i..5-,��0/0 <br /> Last Updated: 05-04-2009 <br />