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a � City of Orono ��� <br /> �, � • <br /> � Buildin Permit A lication g�a� <br /> � NN <br /> Mailing Address: Permit number: 02009� ODD..so1. <br /> O�,0�.O PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: o�–//—09 <br /> a� ,. Street Address: Received by: <br /> '�, Gti�' 2750 Kelley Parkway Plan review fee: <br /> 't.9gE�0g,'�' Orono, MN 55356 � ��� �� <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application for.m 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: �j,j LGnc��,,�Grl� L�r: �l-o�-rv Mh1 553 j �o <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes, a special event pemtit is required with Police Department and City Council approval 60 days prior to the event Shuttle bus service wil!be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ' <br /> MCcr'� �G#.S C'il �w ����„�,ti. (,'-a S� . <br /> State License# r� Expiration Date: <br /> Phone: y,sa -y 7� -6�3 S (office) 6�a -z �v - � � � (cell) <br /> Mailing Address: ��S 1�.�dm urlc �✓�_ City: on v Z�P�SS 3 S� <br /> Contact Person: NJG„rk C'�,�c e� Applicant is: Contractor / omeowne (Circle One) <br /> Email and/or Fax: m�^G� �5�,,�� h s i- c,o:-h <br /> PROPERTY OWNER INFORMATION: <br /> Name: f�G.✓Gn w � l-'lG�r 1c. ��c_s e v <br /> Phone (day): �y s a - H� �--67 �s <br /> Address: a 55 L��dma.-� �r. City: Qy�;�n ZI P: 5S"3 j(o <br /> Emailand/orFax mur,� S�_,�.a,,,,, <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 /> ,�`�S e�rr�?�r� �/`� Fax: 952-471-�82 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ � Z� v o O <br /> APPLICANT 8� OWNER ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department, <br /> • Certify that the information supplied is true and correct to the best of his/her knowledge. The applicant and owner recognize <br /> that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff <br /> has no alternative but to reject it until it is complete. <br /> • The Owner hereby acknowledges and agrees to this application and further authorizes reasonable entry onto the property by <br /> City Staff,consultants or agents, for purposes of investigation of this request. <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 /> Applicant's Signature: Date: �//j ( �� <br /> Owner's Signature: Date: 2�//�G � <br />