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City of Orono <br /> � • Building Permit Application for Internal Work <br /> � (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> O�,L,�,�0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> ,� � ;. s, Streef Address: Received by: <br /> �'� ' '� Gti�' 2750 Kelley Parkway Plan review fee: <br /> L�kESHo�`'� 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: ( � / '? �� <br /> Job Site Address: ,�j .��� �tG �(CVI� � c=C � ���tl Z��� �� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes,a specral event permit is required with Police Department and City Council approval 60 days prior to the event. Shuftle bus service wil!be <br /> required unless appficant demonstrates sufficient on-site parking rs available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: +��1;����.Sf��oF���� ����1,�� i✓ ,����,�s <br /> State License# ��,�,r� ;; ?� Expiration Date: �3- ��_ j� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 9978 <br /> Phone: �(� � ��<� 7 �'�f�� (office) (cell) <br /> Mailing Address: �( � � �u.,,-�e� G�, City: �ra„e ZIP: _S'5.1�s' <br /> Contact Person: ��,�,�y �-�CSr-, Applicant is: o ractor Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: ������i ,SC'�'r��,''` <br /> Phone (day): <br /> Address: �.,r�`-, jF���,�.,���G,— ���_ City: (,✓C{yZ�� ZIP: <br /> Email andlor 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: 7�y;����-���� __� - <br /> Estimated Construction Valuation of Project(excluding land) $ /�/p�� <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 t I the information, the a lication ma not be issued. <br /> ApplicanYs Signature: ���-- Date: (t! �Ki� <br /> Last Updated: 03-01-2011 <br />