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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: �� <br /> ��,j�.� PO Box 66 Permit number: O//—OL�� <br /> Q �\ Crystal Bay, MN 55323-0066�/� Date received: 3 / <br /> s <br /> , �" _ Received by: <br /> ,� � �.� ��; �, StreetAddress: � �� <br /> �'�s, � � '``� G��' 2750 Kelley Parkway Plan review e: <br /> t�kESH�4� Orono, MN 55356 �� <br /> '__��� Total Fee: /3 C,�3. <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)�_��8-�3- I �- [�d.3�-� <br /> GENERAL INFORMA710N: <br /> Job Site Address: �G'7O /�EL[Y I�RRKkJ�fY - �(n/? T^ /02 �StD�vE 8�Y Co��s� <br /> Will this be a Parade of Homes, Remodefers Showcase Home or other Display Home? ❑Yes �'No <br /> /f yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus serv�ce will be <br /> required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ,,,��012�a N ��4+�'I FS L'ONS fRt�lGT.rO� <br /> State License# �os 3��� � Expiration Date: T��� <br /> Lead Certification Number: ,v�� Expiration Date: <br /> (for work on homes thaf w re cons ructed prior to 1978 <br /> Phone: CrJG3� 9?9-31 J 7 (office) �'Gt�� 3G9- 373� (celt) <br /> Mailing Address: P� City: PlE =N ZIP: SS3S`I <br /> Contact Person: �p E �C p�R Str,v Applicant is: Contractor ! Homeowner �c���ie o�e� <br /> Email and/or Fax: • � o 'a o�+ <br /> PROPERTY OWNER INFORMATION: <br /> Name: '�TS���E'NS .T�DEpENC1E�vT t3A�'r!1< <br /> Phone (day): _�',y�� q/S- �'SS� <br /> Address: ,�ppp W� 3�t-'` ST, City: ST. LouJ'S �ARKZ�P SS�II�o <br /> Email and/or Fax rrJy�QSdN �RK��nEfZ �'7�cr�in,��oruraw�c� � ba.+kc:h . ce.n <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> �'Door(s) ��VT'ERTOR �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 /> Phone: 952-471-0590 <br /> ❑ Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Overall Project Description: FSrl,rS H .shl'EGC U/v.IT <br /> Estimated Construction Valuation of Project(excluding land) $ (�S D00 "' <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 generalty 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 e information, the a lication ma not be issued. <br /> ApplicanYs Signature: �C Date: ��'a� �! <br /> Last Updated: 03-01-2011 <br />