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<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 �/
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<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.,,,",
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<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
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<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.
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<br /> ApplicanYs Signature: � , Date: %—r��''� //
<br /> Last Updated: 05-04-2009
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