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.r <br /> - City of Orono <br /> A Building Permit Appiication for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: .�G���– DU ` �' � <br /> �,�,� PO Box 66 <br /> � O � Q\` Crystal Bay, MN 55323-0066 Date received: 09 G' " <br /> I �� �� <br /> � � � �e,.� a, �' Street Address: Received by: <br /> ,�"�t � �'�"� ��/� 2750 Kelley Parkway 0` Plan review f : <br /> 9�i�og,rv Orono, MN 55356 � �`b b <br /> ESH� � �, <br /> — Total Fee:�� a � <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: ��� �`7 �L%j �Vz� � - � ' <br /> Will this be a Parade of Homes, Remodelers Showca e Home or other Display Home? ❑ Yes � ,No <br /> /f yes. a specral event permit is required with Police Department and�City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitfed events will not be allowed. <br /> CONTRACTOR/APPLIClj�NT,INFORMATION: <br /> Name: /t,� e C�Z. r/'�✓ � �' , ���� <br /> State License# � Expiration Date: �' 3/:'�-o,iO <br /> Phone: � � ;. D� office) �Z �,� j �y cell <br /> Mailing Address: ''' '' L?D ��-- /� , Cit ;�` �'� ZIP: _ ��� � � <br /> Contact Person: �>� �� � Applicant is: �Contractor / Homeowner ,c���ieone� <br /> Email and/or Fax: �; ` �Z � <br /> PROPERTY OWNER INFORMATION: <br /> Name: � 'C�E,P'�l L-�f�/�L��S <br /> Phone (day): �jz-., U - l <br /> Address: ��a�o-j L c.���i,U�lj j�r•(�y�� City:���r�.T'� ZI P: '-�� r'�/ <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may re;quire <br /> MCWD review 8�permits <br /> �Door(s) �Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> �Window(s) � ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvci <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehah re .arg j <br /> Overall Project Description:��,' ; J'� • l� � �� -U' i "L. /' � ,Q( <br /> Estimated Construction Valuation of Project(excluding and) $.���' ��� <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 rec;ognizes 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 cann�t be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annua y �ipdate our records and records of other governmental agencies <br /> , re uired b law. If ou refu o u I the inform io ,th a lication ma not be issued. <br /> ,Applicant's Signature: `� Date: � � (� <br /> % <br /> L2s!Update�: 05-0�-200° <br />