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�.`�l <br /> City of Orono c� � � �,� <br /> Building Permit Application for Internal Work �� ti � <br /> . ' (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number. ,�(� � C�- <br /> O�,L,D,�O PO Box 66 _ � �� ' <br /> Crystal Bay, MN 55323-0066 Date received: � <br /> � °'�° .a� . <br /> � ��'� s. Street Address: Received by: � <br /> �'.�n '"�c �ti 2750 Kelley Parkway Plan review fee: "'� <br /> ��kESHog'� Orono, MN 55356 <br /> — Total Fee: � 3 7�. � 3 <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: /7S5 t�x s�. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �J No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to fhe 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: �/n5 f L�,��i�.�s,s LLC ��� ���iP� �S�.cc�t/!� <br /> State License# ��,� �;���Y Expiration Date: 3-3/- l� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: G�;? ��/C ��y/ (office) (cell) <br /> Mailing Address: .b S 7 City: ��,�� �, ZIP: -3< <�' <br /> Contact Person: �=,�� ,��,,s.� Applicant is: ontract / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: _ �✓tct 5 /�6���C ��uc�r�� <br /> Phone (day): <br /> Address: � ?S� t�- c,�' City:(��,�,n� ZIP:� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits: <br /> ❑ Door(s) �Remodel �Water Damage 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: `' {;� ��p� '�;l� ,,z,,� ",���'' �.�1.�,� c.,vf ��> � ,��5 u�f�c,,� � K'/ ` ' � s� -�� <br /> Estimated Construction Valuation of Project(excluding land) $ ��� � �s.��' �' y��-k <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 su I the information, the a lication ma not be issued. <br /> � <br /> Applicant's Signature: �5` (1� �� Date: S �� `' ��� <br /> Last Updated: 03-01-2011 <br />