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� r �� C i ty of O ro n o <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: fd-�� I D <br /> ��,�. PO Box 66 <br /> Q Q Crystal Bay, MN 55323-0066 Date received: � /� <br /> ,� �� :s-�. � Street Address: Received by: <br /> �',�, �� °o%� Gti 2750 Kelley Parkway Plan review fee: <br /> ��kESH04'� Orono, MN 55356 <br /> Total Fe� /G� /`� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �' �v <br /> This application form must be completed in full and all required information must be submitted. �od� <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: '"�� ' � � �, WCt �� '.( � �� 5S 3�� <br /> � -,��CS�Z�r� -- <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Displ y Home? ❑ Yes o <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 rs available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �C�G-�1�C�- �j�►►n <br /> State License# Expiration Date: <br /> Phone: �� � Lg(p - (�q �,� (office) (cell) <br /> Mailing Address: City: ZIP:__ <br /> Contact Person: Applicant is: Contractor / �om_eowner .-��c���ie one� <br /> Email and/or Fax: �-^ <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��� {��r �C'c�;✓� <br /> Phone (day): lc� ?_ (c.�S` I G l J <br /> Address � <br /> L—i � �ti'l ��� 'L_ Cit : � �,�C� ' �t;� ZIP: 5`�� ( <br /> Email and/or Fax ' =�� ' . �� }� <br /> t <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 /> ❑ Sidi ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: �i�_���, � ��,-� -�. ', � <br /> Estimated Construction Valuation of Project(excl' ding land) $ L, � �p <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 /> • 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 /> ApplicanYs Signature: Y��-r-�- Y�-� �- - Date: �� - %� /� <br /> Last Updated: 05-04-2009 <br />