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�� � � � T����� ��� �TM �� <br /> Y� ' a �. �' �;'�� �� ,. ro nn� <br /> � '� _ _ ?. "r ,..'4?-.' ,.�..�� "�' v� <br />����� � � � � City of Orono ��� <br /> 6'S <br /> a� ' ♦ <br />�� � Building Permit Application for Internal Work <br />��� ,;;; <br /> R . <br /> (windows, doors, siding, re-roof, etc.) � <br />� e Mailing Address: <br /> f �,L,�,� PO Box 66 Permit number: <br />��", � <br />� � Crystal Bay, MN 55323-0066 Date received: � <br /> F-:�' O�'� 4�;� O Street Address: Received by: � <br />`� ��,n '� `�" �titi 2750 Kelley Parkway Plan review fee: � <br />�,. 9 � � <br />��-: L kEsxo4`' 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 />� <br /> Job Site Address: ` CS� (,6�'�,�1�� l�'L -� � U(�.� � � <br />�� Will this be a Parade of Homes, Remodelers 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 service will be <br />�;; <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br />� : � <br />� ' CONTRACTOR/A PLICANT INFORMATION: � <br />�.' <br /> Name: S�nJG(�. <br /> State License# 3 Expiration Date: -�3� -1 Z <br />�'. Phone: (�3-�7� - o� (office) <br /> Mailin Address: � � (cell) <br /> 9 lyS -t- ��t�4.1 l � � cit :n1►41' d zIP: 37 <br />��; Contact Person: Applicant is: ontracto / Homeowner (Circle One) <br />�e Email and/or Fax: �,,'3- ���j-- 66pZ� <br /> PROPERTY OWN R I FORMATION: <br />�� Name: KbS� L <br />�j. Phone (day): y��'Z- y y`�_�,�y� �^ <br />�x� Address: �9 a� C��v���� �!-+� City: G�N� ZIP: �S�O <br /> � Email and/or Fax <br /> a.�. <br /> t;;� PROJECT INFORMATION: <br /> k Type of Project: Any earth movement may require <br />� j MCWD review& permits <br />� � ❑ Door(s) ❑ Remodel <br />� ❑Water Damage <br />� � <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.orp <br />�� Overall Project Description: <br /> � Estimated Construction Valuation of Project (excluding land) $ �1QQ `-- <br />�:� � � <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 />:�, <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 efuse to s I the information, the a lication ma not be issued. � <br /> �r ' �__ � <br /> �� <br />� : � _� _ j� <br />�b Applicant's Signature: Date: � <br /> �: �� <br /> � Last Updated: 05-04-2009 <br /> :�'` �• e _�_ 3d �i:: <br /> _. . . . _. _ ... � . _ � .. . . . .. _ .. ..�.i . � � ��� ,�.� � �,,. <br /> ''r.a 'e r�:-�.£� u:.; ..enwr�„ua.+.,°��.� <br />