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J � City o� Orono <br /> Building Permit Application for Intern�l Work <br /> (windows, doors, siding, re-roof, etc.) <br /> �==0� MaiN�gAddres�� permitnumber� �/�� �6� <br /> '� � PO Box 66 � .. <br /> Q Q Crystal Bay, MN 55323-0066 Date received: ,5/ <br /> � ,�i: � StreetAddress� Received by: ` � <br /> � � 2750 Kollay Parkway Plan review fae: � <br /> y H�' Orono,MN 55356 <br /> Tocal Fee; �g� �v <br /> Main: 952-249-4600 Fdx: 952-249-461fi wvyyv,ci.orono.mn.us <br /> 7his application form must be completed in full and all required information must be submitted, <br /> Incomplete applications will be returned. (Plaase prrnfJ <br /> GENERAL INFORMATION: <br /> Job Site Address: 125� �r p„��� (' r��v ri � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,�specia/event parm/r is requ;ied with Police Deparrmen[end Ciry Council approval 60 days prior fo tne avenG S�ut[I�bus sc�rvice will bo <br /> rBqulrod unit�ss dppliCdllf dBmo�SffetBs SllffiCiErtt uri-site pdrkinq is eVB11861e, Nop�OMliltdd evdnts will no!be allnwed. <br /> CONTRACTOR/AI'PLICANT INFORMATION: <br /> Name: k��lnl ��cf'���(�1�,��� <br /> State License# 2 U_ 9 r,i�u� rY Expiration Dato: �j�,���;� f,I <br /> Phone; ����S _��y��� (office) TT (cell) <br /> Mailing Address: — —.r, - Cit �� .,��L _ _ ZIP: y��.�c{3 <br /> Contact Person: ���,, ��,i„ � Applicant is: Contract �;( Homeowner �c�rau o�o� <br /> Email and/or Fax� �.�.�.r�� � �<<,�� ��,c �_•��„��,��+��Li nn-, <br /> PROPERTY OWNEFt INFORMATION: <br /> Name: 5c �� �. S .,��' �qn �'clsur� <br /> Phone(daY)' (y i Z • 3l�o - �3'�? ._ .._ ,._ <br /> Address� 1 • 1c Ci : O � - ZIP: `� .�3� <br /> Email and/or Fax ��„��;��[a n i�l$u n -/ Ma r C ��n-� <br /> PROJECT IN�ORMATION: <br /> 7ype of Project: Any earth movement may I'AqUll'e <br /> MCWD revlew 8 permits <br /> ❑Door(s) ❑Remodel ❑Water Damage <br /> Minnehaha Cresk Watr3rshed District(MCWD) <br /> ❑Window(s) ❑Repair ❑Storm Damagb 19202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑Siding ❑Resioretion ❑Other; (Specify) Phone: 952-471-U58U <br /> Fax: 952-471-06ff2 <br /> Re-roof ❑Fire Damage www innehah�,r.rHak.oro <br /> Overall Project Description: G�bl�R S'F�AIC�_��c� e G.�ZJ�C-.�o __, <br /> Estimated Construction Valuation of Project(excludin�land) $Z�pp,00 _ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agroes to provide all informa[lon requl�ed or requested by the Building DepBrCrrient; <br /> • CertifleS that the information supplied is true and correct to the best of his/her knOWledge. The applicant recogni2es that they <br /> are solely responsible for suGmitting a complete application being aware Ch&l upon failure to do so, the staff h8s no alternative <br /> but�o reject it until it is complele; <br /> • Some or all pf the information that you are asked to provide on this application is classifiEd by State law as aither private or <br /> Confidential. Private data is infOrmapon which generally cannol be given to the public but ean be givon io the subject of fhe <br /> data. Confidential data is informatipn 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 flovernmental agencies <br /> re uired by law. If you refuse to sup ly the information,the application may not be issued. ___._,M <br /> Applicant's Signatute� , Date: � I �• <br /> Last Updated; 05-04-2009 <br /> T0 3Jdd Q�Iflg N9IS3Q �Hfl�i 00�885ZZ56 TT�bT 0T0Z/et/99 <br />