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; . �"�' <br /> q 'x a � s.�� '"s -� <br /> �'� - --, . ., .r-a: . . <br /> 1 ��'y, �'���k�5,�,5 v. d <br /> �:1S ,. ' . � .� �x�a�s'��'�..�'r��'i R:{;��t���+t <br /> � . . <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> '1' (windows, doors, siding, re-roof, etc.) <br /> � MailrngAddress: Permitnumber: �0��- ���� <br />' -�� /�v�,�.� PO Box 66 <br /> � �� Crystal Bay, MN 55323-0066 Date received: ��/7l� '�J <br /> - � v <br /> � i <br /> F , �' s �- Received b <br /> ila �`�t'��_� s,'I StreetAddress: y� <br /> ���'�n� ��,"� �ti;/ 2750 Kelley Parkway Plan review fee: <br /> �vgESH � Orono, MN 55356 <br />� ` -� Total Fee: � ���G .�� <br />'�`�� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and al� required information must be submitted. & <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: o � <br /> f-`' Will this be a Parade of Homes, Remodelers Sh case Home or other Display Home? ❑ Yes No <br />" �" If es, a s ecia/event ermit is re uired wrth 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 IN�RMATION: <br /> N ame: ��� �`" ��S��� a o7 <br /> State License# Expiration Date: <br /> Phone: (� � 2 - / f��- (office) (cell) <br /> Mailing Address: i S"� �, (� Q � �.-L( City: ���0�2 ��- ZIP: � <br /> Contact Person: � <br /> �ue__ C� r , �,,�„ Applicant is: Contractor / �qwp�r (Circle One) <br /> Email and/or Fax � , � �� • �a.� <br /> ;:, , <br /> - PROPERTY OWNER INFORMATION: �" <br /> Name: <br /> Phone (day): ` <br /> � <br /> Address: City: ZIP: �, <br /> Email and/or Fax � <br /> PROJECT INFORMATION: ' ' <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) i ❑ 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 U'� <br /> Fax: 952-471-0682 � <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: � � �,,, � G `, /,,� ' P 1 �4 <br /> Estimated Construction Valuation of Proj ct(excluding land) $ <br /> ;`; <br /> �s; 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; i <br /> �^�t <br /> x • 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 �k_, <br /> � data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> Y 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 /> ,�,. <br /> - �" <br /> �i-; ApplicanYs Signature: � G�--�""����-�' Date: l� U � <br /> � <br /> , /l y`� � L� � _ �N a.. <br /> � Last Updated: 05-04-2009 v ` l C ' '�" l S S , _ � � <br /> _ �-��N� <br />�,;� ..p_.3, __ <br />