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t .� . + <br /> � City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: � � <br /> Og,�,�0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> C <br /> ,� ' �' s, Street Address: Received by: <br /> �' ' "'� �ti�' 2750 Kelley Parkway Plan review fee: <br /> � <br /> \L9kESiIo�`'� Orono, MN 55356 / <br /> `—� Total Fee: ����� <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: � �y � 1i��� /� <br /> Job Site Address: /'`� �' <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> !f yes,a special event permit is required wrth Polrce 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-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �Td wfSf' <br /> State License# ac�oraa 77 Expiration Date: ���,�/-/ � <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (office) (cell) <br /> Mailing Address: (p t,(5� SyLa,�,•� f,f• City: �qy�.t �v�G ZIP: ,5'S.�6q <br /> Contact Person: n,i/ Applicant is: ontracto / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �;�G�1u/ �.34GGP�► <br /> Phone (day): �a- � / ' / <br /> Address: 3 [�,�5 �',Q� , City: ��Gla� 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 /> �Re-roof Phone: 952-471-0590 <br /> ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Overall Project Description: _(�b � 1 G � h�� � <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 su I the information, the a lication a not be issued. <br /> ApplicanYs Signature: Date: �✓�7✓�� <br /> Last Updated: 03-01-2011 <br />