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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: <br /> OQv�,�0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> ���� ' Received by: <br /> ,� -�i s, Street Address: <br /> �' ' '�V� Gti�' 2750 Kelley Parkway Plan review fee: <br /> � <br /> r�kESH�`'� Orono, MN 55356 <br /> � Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This appfication 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: ��f�� �r �� h �-+'`. �� c���; t� i j'i,'( in _S �.� -`' � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes,a special 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 applicanf demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP...�ICANT INFORMATION: <br /> Name: �LL�c /' �J��"�lC'f=.S � � � <br /> State License# �������,��` Expiration Date: .J�' --?c�/Z_ <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were consfructed prior to 1978 <br /> Phone: _���3 - -�cZ -j-� 2 3 (office) (cell) <br /> MailingAddress: /�,,c�,�,� .�'r 5,`:�c �- City: /��� L�- ZIP: <br /> _S"S� �.� <br /> Contact Person: ,�v��.- Applicant is: n rac o� Homeowner (Circle One) <br /> Email and/or Fax: ��� . �%Z � _ 2�.:� ' <br /> PROPERTY OWNER INFORMATION: <br /> Name: .��� �i�,f e� G��>r/c. 1..�.-z c' <br /> Phone (day): ��Z - ��� - y�-S� <br /> Address: _3 `f/S� fN��; L, �:�i , City: ��r�„ia ZIP: �� �-5"� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel �f,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.orp <br /> Overall Project Description: �L�r���� �- ��-i�,.-.� l«��,� -- ,�- ��• / � ��,..=�-- F- <br /> w. >� : LiL%�f l�� r �C J ci � <br /> Estimated Construction Valuation of Project(excluding land) $ 7 "�l��s i5"� �� <br /> , <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 /> � ;�_�-Y,,,�.,,,, <br /> Applicant's Signature: �``""'� '��'"'"_� -'" � �� Date: `j "' Z ��- ��' I l <br /> Last Updated: 03-01-2011 <br />