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City of Orono
<br /> Building Permit Application for Internal Work
<br /> �~ (windows, doors, siding, re-roof, etc.)
<br /> � Mailing Address:
<br /> �,D,�r PO Box 66 Permit number:
<br /> � Crystal Bay, MN 55323-0066 Date received:
<br /> � , � �
<br /> i� �� �� ,-.- �j Received by:
<br /> ,� t� ��G-_:��� �, Street Address:
<br /> �'.�, � ° �� Gti 2750 Kelley Parkway Plan review fee:
<br /> t9'kESH04� 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: ���� �f,�„ �:��,L �i_��`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 applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: �T/�s�o;� �rS��n.��� ��,�
<br /> State License# ,;��3r 57 S Expiration Date: 3- �/ — t
<br /> Phone: /�3- �j - �p�i office cell
<br /> Mailing Address: �" 5 i ,� ;dj � � ' J"' Cit : � ZIP: `,_j,',� `
<br /> Contact Person: � ,t., Applicant is: on ract / Homeowner (Circle One)
<br /> Email and/or Fax: �G3��/75�-��G��� � ,��.-.��, �o�a . �>�
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �l_";��� /�/'E./r,•, �.�r
<br /> Phone (day): ��:3 - �-5� �
<br /> Address: ,Cvo ��C��t� p� City: �i/f.J� v ZI P: J ,S.3i /
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> MCWD review&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 /> Fax: 952-471-0682
<br /> ❑ Re-roof ❑ Fire Damage www.mi nehahacreek.or
<br /> Overall Project Description: ���,,� �.,�,1' � /f;�;,-l� �,�,,; �_ t ��,t„ �„ � ,, )
<br /> Estimated Construction Valuation of Pro'ect excludin land $ "��
<br /> 1 ( 9 ) .SJ 5 vv�-�,
<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 alf 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 sy �t e inf ation,the a lication ma not be issued.
<br /> �� �'
<br /> Applicant's Signature: ��,ti ? ,��� Date: �„y � � ��/U
<br /> Last Updated: 05-04-2009
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