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<br /> City of Orono
<br /> Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailrng Address: �, >�
<br /> Permit number: - �' .�� �� �S
<br /> �.,�,� PO Box 66 !,
<br /> :�
<br /> � Crystal Bay, MN 55323-0066 Date received: / O
<br /> � �;�.�,�--� O ��
<br /> � �"�'�?���z� a,r,� Street Address: Received by:
<br /> �' ' � 2750 Kelle Parkwa
<br /> � ';� � Y Y Plan review fee:
<br /> L�kEsi-�IO4'�' Orono, MN 55356
<br /> — Total Fee: �/�'� ��
<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. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: 'i�,�� d i� 1�(�, +%���u q `7' 1'sV C-
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No
<br /> If yes,a special event permit is required wrth Police Department and City Council approval 60 days prior to the event. Shuttle bus service will6e
<br /> required unless applirant demons}rates srfficier,t or.-site parki^g is avalab;2. h'or-,-p�;rnitied e✓ei�ts wi11 noi be aiiowea.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: ~—'� �1�vy`t,�� ti,4 /L�1Ll (�
<br /> State License# Expiration Date:
<br /> Phone: ��5'�--� ��� l �- `k'�S'`1� . (office) (cell)
<br /> Mailing Address: 1��� p U�y �Vvc� �}y V 1�. _ Cit :W ta-'�yg-1�- ZIP: ,��5 3��
<br /> Contact Person: ,,�yv�n,.S p � i� �,(A y�p;�,.�,p�,q,�, Applicant is: Contractor / omeowner . �c����e o�e�
<br /> Email and/or Fax: ���^}� ..... �� 4 .� p;,-y,.c� �►.-�.X
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: _� j��,�t�.+, h�.i,� �11M i►�� t+�I�U�.
<br /> Phone (day): 9��1.�'t'��— �Sg y b .
<br /> Address: �.��(d � U i�( u3c��J�y p�/ +� Cit :�A,�`�Z/�-�� ZI P: �a�`1 i
<br /> Email and/or Fax �5 L -•�t 1�-� �?-�5-'��, �-A-'k
<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 /> r 8x: 9�2-47 i-vo82
<br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> Overall Project Description: �vJ� yy,�c��,� r?��p,y� �,y,;�j �1,����� /��� V„t�k�.,u- V�,�►� i!���5
<br /> Estimated Construction Valuation of Project(excluding land) $ ���pCp�
<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 /> ApplicanYs Signature: ������ Date: (��L.i_D-:'1�VS t►a.. `t 1�CX:��.
<br /> LastUpdated: 05-04-2009
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