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t•!�, r ^� / I 3 3 S <br /> , , - _ _ <br /> _----- — -- <br /> � � <br /> - ,---E��--__—� � L�1`.`"�_l� t t e ,=� —�.�r"'7 /,_ � ,.'�\ �v1 (�- Ii�CE'��,. <br /> _ .— <br /> ��1��� _._-- ---- C i ty of O ro n o ' �.l ,_�,l� <br /> RE <br /> ' , �l�uilding Permit Application for Internal Work �-��'�'�` �� <br /> �F� '� (windows, doors, siding, re-roof, etc.) <br /> R Mailing Address: Permit number: <br /> ���� <br /> PO Box 66 <br /> � Crystal Bay, MN 55323-0066 Date received: <br /> /O O \ <br /> �; <br /> �'�a ��✓ ,�j; Streef Address: Received by: <br /> � � :� ������'��� �'� 2750 Kelle Parkwa <br /> ��L � ° Y Y Plan review fee: <br /> `�kEsxo4''� Orono, MN 55356 <br /> �- — Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www ci oronomn �s <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: � �:'���c''�u� ' <br /> � � � <br /> Job Site Address: �� L �- ���C•,E`' �� L; -( ��'�C � �-, `�', �� �� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No <br /> /f yes,a specia/event permit is required with Police Department and City Counci/approval 60 days prior to the event. Shuttle bus service wi/l be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: , <br /> _- ' � <br /> _. <br /> N8f11@: �� �` lt�i L- �� i ��i � �<<j�,, ;(.� ��,�._�.� `�l(" `��`--`� <br /> State License# 1 � �� �� C `, Expiration Date: 3 � ?,�:;1 c� <br /> Phone: (,r51 - Z-`_:>7 " y � (office) (cell) <br /> MailingAddress: (���� l�z;�.����=�-:� �� � > Ciry: - ; , ,%:<�;�. ZIP: � � , � i � / <br /> Contact Person: _E� th�> +_--�� -�v� Applicant is: C(ontractor� / Homeowner (Circle One) <br /> Email and/or Fax: (; �� t �- > �( �(� �_�i <br /> PROPERTY OWNER INFORMATION:. <br /> Name: ` i��_�-- l���C��4�-,�-,'t�i-i� ( <br /> Phone (day): ; ?� (- >`� � �� <br /> Address: 11cr�. �(C..�ti�� � �;1cE City: �'��t t�. �- ZIP: � ,.. -.,����::- <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br /> i Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) �Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> �/ Deephaven, MN 55391 <br /> L�4 Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> T � <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ ' "�(�%'L; ' -- <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 information, the a lication ma not be issued. <br /> i��_% _ --- <br /> ApplicanYs Signature: - Date: �2- f C"�� ZC�_ �j <br /> � <br /> � <br /> �.- ,�.,, <br /> Last Updated: 05-04-2009 � �---__ <br />