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. . si. �` ` P 'x s '-!6 � .�'..TYa'� <br /> � 3 � <br /> .. � ��` �`�t RtA <br /> M � <br /> . � '. ``"1 ..�s ' _ s��s K�'t� <br /> C ity of O ro n o ��_ � <br /> `� �� <br /> ` Building Permit Application for Internal Work ����� <br />� <br /> (windows, doors, siding, re-roof, etc.) �� <br /> �� <br /> �O� MailiPO Bo�r66 . Permit number: D D - 07 7 £� <br /> Q Crystal Bay, MN 55323-0066 Date received: �� /v � <br /> � \ � <br /> I <br /> � ����,��-;;,;, � Street Address: Received by: � <br /> - � �ti 2750 Kelley Parkway Plan review fe � � <br /> `• � `v Orono, MN 55356 � � <br /> L9kESHo4' � <br /> Total Fee: p� �l �• � � � <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. (P/ease print) „. <br /> GENERAL INFORMATION: � <br /> Job Site Address: ':��t�Z �,��E�1 U�� ,����,`� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �lo �� <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/ PLICA T INFORMATION: � <br /> Name: �-- S ��,�� , <br /> State License# � i� 7 y Expiration Date: �L-lZ � <br /> Phone: "? - � - �`7�� office cell �� <br /> Mailing Address: � S ��' � ��t,�,Jg1, ��� Cit : q4�1.; ZIP: 5� � <br />�.' Contact Person: Applicant is: Contractor / Homeowner (Circle One) �� <br />�= Email and/or Fax: ' <br />�` � <br /> �:� <br /> PROPERTY OWNER INFORMATION� �� <br /> Name: r� �'(`� ���� �°� <br /> Phone (day): - ,�� p g� /' � <br /> Address: �� �02 �� ��Z , City: � ZI P: �S 3S b �� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require Y� <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 /> e-roof ❑ Fire Damage www.minnehahacreek.orq � <br /> Overall Project Description: <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 /> '� <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 /> ' t Z / �'� <br /> Applicant's Signature: Date: � � J� - l � �' <br /> . aj� <br />'� Last Updated: 05-04-2009 , y� � � <br /> S ' `£ � <br /> __ .....s �� i �.�. ,.�. ..�..+ . . .� 3�.a.. . _� sf . ,..v...d�,r�.w.."�L ��.f..M 3u�u�l._.,a�.'�t+"Si <br />