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City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> MailingAddress: Permit number. l/�%'`A DO .Z� <br /> �v�� PO Box 66 <br /> ` Crystal Bay, MN 55323-0066 Date received: �p /!r G <br /> ,/o �:n., O �, <br /> I '1.1� �'�,, <br /> �� ��'����; s.i� Streef Address: Received by: <br /> �'� �'�� ���� � 2750 Kelle Parkwa <br /> , ��� Y Y Plan review fee: <br /> t`�.rfESHo�`'� Orono, MN 55356 � <br /> Total Fee: ��9 Cl� <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: -�- ��, � <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 applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: I�iDIL �����.��..s T�►.�� <br /> State License# (�L._ a�L,1 Expiration Date: ���_ o���_ <br /> Phone: _�,� _ �oq_ g�j,2.. Ce.ts2 (office) �6� _ a9S- '��S'�, (cell) <br /> Mailing Address: u T Cit : o,._-�:c�� ZIP: S S 36 2 <br /> Contact Person: t� `�,,,,,� Applicant is: ontra / Homeowner (CircleOne) <br /> Email and/or Fax: 7�3- � s S_ ��g� _ ��� <br /> PROPERTY OWNER INFORMATION: <br /> Name: Q��-.�.rL, Sc�•�,J <br /> Phone (day): �4�—e..��3- ds(,d <br /> Address: qq�.1 ,�1�,,`-'t- F"4R.a,� R6., City: Lo�.�. �.� Z�P� SS 3SL <br /> Email and/or Fax <br /> PROJECT INFORMATION: �07� d�D� � <br /> Type of Project: � Any earth movement may require <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 Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> ❑ Re-roof Fax: 952-471-0682 <br /> ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: �,�� �Qs�t� (����,�,�,� <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 ma not be issued. <br /> ApplicanYs Signature: � ��Date: (v � �(- �o/a <br /> ��.�� J� rL:-.�. SI�_ <br /> �ast Uodated: 05-04-200� <br />