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. �i ► <br /> City of Orono c�� <br /> Building Permit Application for Internal Work <br /> j � (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: —�Q � <br /> Og,D,�O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: / / <br /> � �_ <br /> � Received by: <br /> �,� �� �.,���, �, Street Address: <br /> �'�c, � '� �,titi 2750 Kelley Parkway Plan review fee: <br /> r�kE5H0�'� Orono, MN 55356 /� <br /> Total Fee: _�y 395; 7� <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: �,��2�1 {�P�✓ �,/��,� �✓v� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> !f yes, a special event permit is required with Police Department and City Council approva!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 INF9RMATION: <br /> Name: t'�1L ��J�'�S-j-�/.l.�C'�cc7h ,c�{/\� <br /> State License# Z�;�7 7 5'� Expiration Date: '�j � '3 ( �Zb�/� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes fhat were consfructed prior to 1978 <br /> Phone: �j12, �p(� � p�Z.� (office) (cell) <br /> Mailing Address: ��� h�,/� City: �,f ZIP: �-.S� . � <br /> Contact Person: ,K,� � GuS� �.�. Applicant is: Contractor Homeowner �c���ie one� <br /> Email and/or Fax: f'� ��� � �,�, " � � � <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��.1.t1r `� �c.:�cti�rC'� ��--��� <br /> Phone (day): �l.j� ; �.7 � , �'�� � <br /> Address: Zyi�2� �,�r%,�.; c„r,� c�ty: �� v ziP: ��,� <br /> Email and/or Fax ...- <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) Remodel ❑Water Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Overall Project Description: (1'�q�{�i ��,h �'�.-p�t;��� <br /> Estimated Construction Valuation of Project(excluding land) $ �'Z k�c�s <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 ctassified 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: ,'` � Date: �p � / <br /> Last Updated: 03-01-2011 <br />