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<br /> � City of Orono
<br /> � Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number: v— (�
<br /> �v�\ PO Box 66
<br /> �Q `\ Crystal Bay, MN 55323-0066 Date received: 9 /�
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<br /> �, � Street Address: Received by:
<br /> � " i°'"' v� 2750 Kelley Parkway Plan review fee:
<br /> ��kESH04� Orono, MN 55356
<br /> Total Fee: /���l�
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �(,�Je� ,6 , �/��,y,�� �N
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be returned. (Please print) ,�J �..,� �j,�,-v��c�
<br /> GENERAL INFORMATION: P
<br /> Job Site Address: �1ZG L�:��� �u� y-�� �v
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ,�No
<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 wil/be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: � LLL
<br /> ; �: tt ;�
<br /> State License# Z��;35 3 jZ Expiration Date: 3 3� �i�
<br /> Phone: ��Z_Z��j_ yyR p (office) ��z - ci �-- �7 2--5 (cell)
<br /> Mailing Address: � �,� q0 � Cit : ►G; ZIP: s
<br /> Contact Person: ��� �-}��,,,5.,,,«„�� Applicant is: / Homeowner (Circle One)
<br /> Email and/or Fax: _7��-yZ2_1����
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �]u.��t .� �Ll���� L;��s�_�,
<br /> Phone (day): �(c3_ z21 -3qlo3
<br /> Address: q2o ��,t,�� �,,•.� City� d�� ,�, ZIP�
<br /> Email and/or Fax �1
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑ Door(s) ❑ Remodel MCWD review&permits
<br /> ❑Water Damage
<br /> [�Window s Minnehaha Creek Watershed District(MCWD)
<br /> ( ) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> Deephaven, MN 55391
<br /> ❑ Siding ❑ Restoration � Other: (specify) Phone: 952-471-0590
<br /> ❑ Re-roof Fax: 952-471-0682
<br /> ❑ Fire Damage �h St�fl a-�•-, ,SL.Qr �e-!.0 www.minnehahacreek.orq
<br /> Overall Project Description: " r,.�.� �� ���� , i3«",,, ,� � 42�• � 1�t� L w. ,.. , ��, {- ,�u =_
<br /> Estimated Construction Valuation of Project(excluding la ) $ �jZ�� J��n�•���, �.���i�y..
<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 /> Applicant's Signature: ��/a�'/j Date: ��2��p
<br /> —�.
<br /> Last Updated: 05-04-2009
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