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. �,i� <br /> G�ty of Orona �f?r <br /> , . Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> �1�lai6ngAddress: Permitnumber: D O/O—���0 <br /> � �,�,�. ` PO Box 66 7/ <br /> ;/Q � O��II Cryshal Bay,MN 55323-D066 Date received: /! � ld <br /> (� �$'��'°� I Received b <br /> �a ����.�: s,� StreetAddress: Y' <br /> ��`'�` � 1 2750 Kelle Parkwa �� <br /> ���• ,, ' ''"� ��;' Y Y Plan review fee: <br /> �L � ��� Orono, MN 55356 <br /> �ESH04`'� � .' <br /> - - To4al Fee: <br /> Main: 952-249-4600 �ax: 952-249-4616 wwvr.ci.orono.mn.�s <br /> This application form must be compleied in full and all required information must be submitted. <br /> Incomplete appllcations witl be returr�ed. (Please print) <br /> GEN ERAL INFORMATiON: `/ <br /> Job Site Address: 3`f U� �i�'S✓ GF'i�t .S'T- <br /> Will this be a Parade of Nomes, Rem�delers Showcase Horne or other Display Home? Yes No <br /> lfyes,a specia!event permil is required with Police Departmen�and City Councii aop�va!60 days prior to t';e event. Shutt(e bus serviee will be <br /> requi�ed un�ess apprica;f demonstrafes sufficlen!on-site parking is available. Non-permrCed avenfs w,71 no!be allowed. <br /> CONTRACTOR/APPLI ANT INFORMA I N: <br /> Name: ��YL�/Y �?/��/I��� (/`h�/i��01'�//Y <br /> State License# Expiration Date: <br /> Phone: L- Z ZS office - L,SI- a(�8� cell <br /> Mailing Address: �TGlG��¢NN� �l2• Cil :�oGO�i✓ <br /> Contact Person: L�/1/ /�/��D2 Applicant is: Contractor / Homeowner (Clr�le One) <br /> Email and/or Fax: /j/ �/G• �.O","Y1 <br /> PROPERTY OWNER INFORMATION: <br /> Name: ,+��yCE/✓ �'1/�7�T�7�'2� <br /> Phone(day): �p.S - -z S/- o ���,P <br /> Address: �� v� ��5 T G z S' T� City: U��'�✓�> Zf P: .J 5 3 -� � <br /> Email and/or Fax KA>GE�v W'F�/�2�7�/n�/L -�'..vm <br /> PROJECT INFORiV1ATION: <br /> Type of Praject: Any earth movement may require <br /> MCWD review 8 permits <br /> � Door(s} ❑ Remodel �Water Damage <br /> M;nnehaha Creek Watershed District(MCWD) <br /> �Window(s) ❑ Repair ❑Siorm Damage 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> ❑ Siding ❑ Res�oration ❑Other. (speciFy) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage � ww�v_,minnehahacreek.orq <br /> Overall Project Description: E j+tiB�/�� ��'�E AcE- .r'ff£�TRFcK�LSKL�o�/ /�✓�/�Gf��/�/ �//`�"S��' <br /> Estimated Construction Valuatiun of Project(exciuding land) $ Sva . � '�� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all informalion required or req�ested by the Building Deparlment: <br /> • Certifies t�at the information supplied is true and correct to the best of hislher knowledge. The applicant recognizes that Ihey <br /> are sclely respo�sible ior submiiting a complete application being awarE that upon failure to do so,ihe staft has no alternative <br /> but to re�ect ii until it is�omplete; <br /> • Some or all of the information that you are asked io provide on this app3ication is classified by 5tate law as either private or <br /> confidential. Private data is information �vhich generally cannot be given to the public but can be given to the subjecE of Ihe <br /> data. Confidential data is information which gene,rally cannot be given to either ihe public or the subject or the data. Our <br /> purpose and intended use of this information is to annually updale o�r records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I thz informalion. he a lication ma not be issued. <br /> ApplicanYs Signature: Date: �l Q <br /> Lasl UpCaled: OS-04-20G9 <br /> L'd 8Lb8-OL8-Z69 eaoua�iyM ue��ey{ dOt��£0 06 LZ Inf <br />