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Sep 30 �11:21 a Schenkel 9524701781 p.4 <br /> � <br /> � City o� arono � <br /> B�ilding Permit Appiication for lnternal UVork <br /> (windows, doors, siding, re-roof, etc.� <br /> Maiiing Address: Permit number: ���f�// ,� <br /> Og,O,�.O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: ��,3D/ <br /> �, � StrgstAddress: Received by: <br /> �'�, �ti 2750 Kelley Parkway Pfan reviewfee: <br /> ��p4,� Orono, Mi�55356 <br /> Tntal Fee: ��� �� <br /> Main: 952-249-4600 Fax: 952-249-46'�6 www.ci.orono.mn.us <br /> This applicatiort form must be completed in full and all requirad in€or�ation must be submit�ed. <br /> lRcomplete applications will be ret�rned. (P/ease prirrf) <br /> GENERAL lNFORlIAATION: / <br /> Job Site Address: �� 7� ��'� ��.�/`J LP"�- <br /> Will this be a Parede of Homes�Remodelers Showcase Home or other Qisplay Home? Yes o <br /> If yes,a speciel event permit rs req�ired with Police Deparlment and City CoLncil apprnval 8D days prior to fl�te everrt. Sf�uttle trus service will be <br /> required uMess applica�demoRstrates sut�cient on-site paricing is availeble. Nor-permitted events will not be ellowed <br /> CO�ITRACTORlAPPUCANT INFORMATION: <br /> Name: �n,c.�i� �,n�-u-r'�r�S�-.S �� C <br /> State License� �� � , ��3� Expiration Date: J3 <br /> �ead Cert€ficafion Number. N A-'r i l�1 YC�—r Expiration Date: �'—�� <br /> (for work on homes thaf were consbcrcted prior to 1978 <br /> Phone: ��� �f 7�- d�� (ofnce) {cell) <br /> Mailing Address: �� ,y� )„�dC City: S �y�l ZIP: ,7,��!s^�3� <br /> Conta�f Person: �j� Applicant is: Co t;actor / Homeowner �ci�ie o�e� <br /> Email and/or Fax �,,2_ y 7� — �7�� <br /> PROPERTY OWNER Il�FORMAT dN: j • <br /> Narr�e: ��r� � �G-�- e�� ! ✓�-r <br /> Phone(day): � <br /> Address: City: ZIP; <br /> Email andlor Fax <br /> PROJECT 1NFORMATION: <br /> Type of Project: Any earth movement may�equ9re <br /> ❑Door(s) ❑ Remodel ❑Water Damage MCWD review S permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ SfoRn Damage 78202 Minnetonka Blvd <br /> ❑5iding ❑ Restorafian � Other: {specify) Deephaven,MN 55391 <br /> P h o n e: 952-rF7'E-0 59 D <br /> `�Re-roof ❑ Fire Damage Fax: 952f171-0682 <br /> i <br /> www.min rtehahacreek.orq <br /> �vera(I ProJect Description: <br /> Estimafed Construction Valuation of Project (excluding land) $ J a ��d . „ <br /> APPUCANT ACKNOWLEDG�MENT: <br /> � a� <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 knovdedge. The appfit�nt recog�izes Qhat ihey <br /> are sofely responsible for submitting a compleie appfication being aware that upon failure to do so,the stafiF has no altemaiive <br /> but to reject it until it is compkete; <br /> • Some or aCl of the information that you are asked to provide on this application is classified by State law as either private or 1� <br /> confidential, �rivate data is information vrhich generally cannot be given to the public but can be gnren En fhe subject of the <br /> data. Confidentiat 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 i rmatio� is o annually wpdate our records a�d records of o#fier govem ental a encies� <br /> re uired b law. lf ou refuse to su the info ation,the a licatian a not be issued. <br /> App�icanYs Signaie�re: Date: <br /> laat Updated; 03-Ot 2011 ��3 V —�r <br />