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City of Orono �� �5 <br /> � ' Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> MailingAddress: Permitnumber: Q//- 6� <br /> O�,L,�,�0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> �`� <br /> a� � .-� �. Street Address: Received by: <br /> �' ' ''� �titi 2750 Kelley Parkway Plan review fee: <br /> ���kESHo�`'� Orono, MN 55356 <br /> Total Fee: ��Q,� <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: J <br /> Job Site Address: � `'� �5 �j��� f- �/��- �s/jGr� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> !f yes, a specral event permit is required with Po/ice Department and City Counci/approval 60 days prior to the event. Shuttle bus service wi//be <br /> required unless appficant demonstrates su�cient on-site parking is available. Non-permitted events wil!not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �"2 i iC�(�F`'S� <br /> State License# , �,�,(c; 7 Expiration Date: ��s'- �—/3 <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were construcfed prior fo 1978 <br /> Phone: ��' �. _ ��� (office) (cell) <br /> Mailing Address: 5/ C"C<<ti�� �� ��- City:r�7l� l( c�E�t� ZIP: �j'�G <br /> Contact Person: ��>�-Z� Applicant is: rac / Homeowner �Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: -- <br /> Name: 5�ti;���:-t:;(? E.-��'�C�.���'' <br /> Phone (day): <br /> Address: � �,j o��P �t �c-rl� ��,�2y City: (��'`�U 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: � �t��- � f--F ,�- ��G{ � <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 to u I the information, the a lication ma not be issued. <br /> ApplicanYs Signature: Date: �'���� ��r <br /> Last Updated: 03-01-2011 <br />