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<br /> City of Orono
<br /> Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number: Q –Q��7�
<br /> g,�,�. PO Box 66
<br /> 0 ` � Crystal Bay, MN 55323-0066 Date received: � /�
<br /> � � �'`����-�`��, �, StreetAddress: Received by:
<br /> �. �
<br /> �'�, '" �ti�' 2750 Kelley Parkway Plan review fee:
<br /> l-9kESHp4'�' Orono, MN 55356 �
<br /> —" Total Fee: ��� '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: - -
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No
<br /> If yes, a special event permit rs required with Police Department and Ciry Council approval 60 days prior to the event. Shuttle bus service will be
<br /> required unless appficant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name:
<br /> State License# ' �-, Expiration Date: .�� � ; ��
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were consfructed prior to 1978
<br /> Phone: . , �; _ - �.->; (office) � (cell)
<br /> -�,_.�_.
<br /> Mailing Address: �����, T�:zust,,, ,�� �; �- ,t� Cit : .�.;,,-:� ��-;, . �� ZIP: <. �- ,, c�����
<br /> �:
<br /> Contact Person: T�, l�u_����_�.; , Applicant is: ontrac r / Homeowner �c���ie o�e>
<br /> Email and/or Fax: �, , • _ �. ;�� _ , ;
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: � . -
<br /> �. �
<br /> Phone (day): �;�� , 7; ���,�>
<br /> Address: �� � �° / ; / City: ,%�, , ZIP: `" � �'�
<br /> �� s F=� ,�., , - ..
<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 /> [��2e-roof ❑ Fire Damage Fax: 952-471-0682
<br /> www.minnehahacreek.orq
<br /> Overall Project Description: ": :- f� �: �', / �,:;? �,.
<br /> Estimated Construction Valuation of Project(excluding land) $
<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 t su I the inf r ation, the a lication ma not be issued.
<br /> ,
<br /> ApplicanYs Signature: i/ �%:.f, �,-'% �., Date: ; - J;' -� / j
<br /> Last Updated: 03-01-2011
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