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<br />� :� City of Orono � ��=�r �
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<br />��, ' Building Permit Application for Internal Work �
<br />��
<br />��_ (windows, doors, siding, re-roof, etc.) �
<br />��, �
<br /> Mailing Address: Permit number.
<br />,��;; ��,� PO Box 66
<br /> t Crystal Bay, MN 55323-0066 Date received:
<br /> � � �� �
<br /> 4 �
<br /> � ����-�` �, ' Street Address: Received by:
<br /> � ��
<br />��` �'� 2750 Kelle Parkwa
<br />�<x `'�' �� Y Y Plan reviewfee:
<br /> L9.gESH�g,�' 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: � 1
<br /> r�; Job Site Address: � �r I.�ILt� �q�- � ��:%,�.� �
<br /> 3#- Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ��lo
<br /> '` If es, a s ecial event ermit is re uired with Police De artment and Cit Council a
<br />�,• Y p p q p y pproval 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: �(/`-S� 1 `j0�
<br /> State License# �� �,�' Expiration Date:
<br /> Phone: ' �— o� office cell
<br />�� Mailing Address: �yS S`J � -i� ( Cit : 1,�3 r✓ ZIP: � S ,
<br /> Contact Person: Applicant is: n ra or � Homeowner (Circle One)
<br />�'.
<br /> x��; Email and/or Fax:
<br />�; PROPERTY OWNE INFORMATIq N: .
<br /> � N �F S��-(�
<br />�.,,; Name: ���� a
<br />�� Phone (day): ��'2•• �i 3 --z t-��� �
<br />�; Address: (�Z� �,y�TU�,inl l�►�.IC. City: �r�=i�c� ZIP: `SS �S �
<br />�K�{-, Email and/or Fax
<br />�;�>;;
<br />:;,;;
<br />�� PROJECT INFORMATION:
<br />�:j Type of Project: Any earth movement may require
<br />�`" MCWD review&permits
<br />�;..
<br /> ,: ❑ Door(s) ❑ Remodel ❑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 />� Re- oof ❑ Fire Damage www.minnehahacreek.orq ,�
<br />� Overall Project Description: �
<br /> Estimated Construction Valuation of Project(excluding land) $ , � • �
<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 />�s> 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 /> s�.r?
<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 /> :� ` Y+
<br /> �" �
<br /> ApplicanYs Signature: Date: (� � � �^ �� �
<br /> �Last Updated: 05-04-2009 �
<br />�-�-. b� : ��x�WF�' �-' s f .-,tt � Y.. 3 ,��` �Ai
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