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���-, i <br /> . <br /> City of Orono � � k� ► � <br /> " Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: <br /> �,�,� PO Box 66 Permit number: c�O! -- DUG�f <br /> 0 � � Crystal Bay, MN 55323-0066 Date received: l �i0 �/ <br /> ���a��� <br /> ����- s �- Received b <br /> �,�F�;� s, Street Address: y� <br /> �'�nt y" �,� 2750 Kelley Parkway Plan review fee: <br /> �kESHO�`'� Orono, MN 55356 _ <br /> Total Fee: � � (��j v.� <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. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: � �� -�-o ,�`��� r '-``�""''�} � �"��`" <br /> Job Site Address: �`�v2J �t�«, �,;,c_;�Q�.� ,v�; ��C,�,.• v�v���-� •=-�e �. <br /> Will this be a Parade of Homes, Remodeters Showcase me or other Display Home? ❑ Yes ❑ No �-2�'-11 <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 sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: /�'Ii�%/o`l 1�!��cs %��.�c� <br /> State License# ���; � Expiration Date: �?c�2 <br /> Phone: c� �2. � 7�_-r ��y (office) — (cell) <br /> Mailing Address: �y2� �:.� �"�•�� s.��� . � Cit : u,�a:�t 1�� ZIP: �s 3c,�-� <br /> Contact Person: �-,,���- Applicant is: Contractor Homeowner (Circle One) <br /> Email and/or Fax: �U,,,.� /���� _`;�,r�.,,,� ,� �:.:.,,-;'/ ,cz.,,,", <br /> . <br /> PROPERTY OWNER INFORMATION: <br /> Name: c�c.�,�.� SirN�.��c <br /> Phone (day): �1;2- s 6<r. c��5� <br /> Address: � /��, ,���� -- City: ct/,,.,,, ZIP: <br /> Email and/or Fax <br /> � l 2�; <br /> PROJECT INFORMATION: � ��zc-n%��� v�L�,..li Y'�� ;; �-�-•��, c,i, L� � ^� <br /> Type of Project: Any earth m vemen may require <br /> MCWD review&permits <br /> ❑ Door(s) ,�2emodel ❑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: <br /> Estimated Construction Valuation of Project(excluding land) $ �� jo�. •�` <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 /> � <br /> � <br /> ApplicanYs Signature: � , Date: %—r��''� // <br /> Last Updated: 05-04-2009 <br />