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C.•�`„"�-'r' .J � <br /> r City of Orono q/rz��o ��;�!�f ��/ � <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Add�ess: Permit number: �0�0 -Oo8'S3 <br /> O,.g,��.0 PO Box 66 <br /> Crystal Bay,MN 55323-0066 Qats received: q <br /> � o. Street Address: Received by: <br /> �, �.,f` 2750 Kelley Parkway Plan feview fee: <br /> ����$ Orono,MN 55356 <br /> Main: 952-249-4600 Fax: 952-249-4616 �MNw.Ci arono.mn.us Tot�l Fee: �G�Z, '�'!a <br /> This application fo�m must be completed in full and all requi�ed information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: /S$b �-o'h L�ke ✓dl�r�0, <br /> Will this be a Parade of Homes, Remodelers Showcase Home o�other Display Home? ❑Yes No <br /> 1/y�s,a special evenf permit is required with Polic�Department and C�ty Council appiov�l 60 days pnor to the event. Shuttle bus service will De <br /> required un/�ss applicanr demonstrafes sufficient on-sif�p�ricing is available. Non•peimifted events wil!not be allowed. <br /> CONTRACTOR/APPLICANT INFORMA710N: , <br /> Name: r���� s� �r�ve� s�{��u�(«,., <br /> State License# ZO�o3a�eSS Expiration Date: y � I� 3t /l <br /> Phone: ��3- 1a3�-'��3� (office) (o�-E31��2�i0S (cel) <br /> Mailing Address� 1 33�� S I» s�!� r✓ Cit : l erf�e,r- ZIP: �3'.�0 <br /> Contact Person; f ?�.;I I: S Applicant is: ntrad / Nomeowner �Circle One) <br /> Email and/or�ax: ��� ��n . ��^ �(�3-�33-� 9�S1 _ <br /> PROPERTY aWNER INFORMATION: <br /> Name� S�'�'�!E �s�ronbJal ( <br /> Phone (day): l2� 5Sr! ����5 <br /> Addr�ss: �sg(� �o n r Lc.l�P !�'�- City: Q,Zir,C� ZIP: �'�� <br /> Emai1 and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any eatth movement may require <br /> MCWD review 8 permits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br /> ,_./ Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair �5torm Damage 18202 Minnetonka Blvd <br /> �eephaven, MN 55391 <br /> ❑Siding ❑ Restoration ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> [6�e-rooF ❑ Fire bamage www.minnehahacreek.orA <br /> Overall Project DesCription� <br /> Estimated Construction Valuation of Pro��ct(excluding land) $ loSaO = St�/�Ct.P� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provida all information required or requested by the Building Department; <br /> . Certifies that the information supplied is t�ue and correCt to the best of his/her knowledge. The applicant recagnizes that they <br /> are solsly responsible for submitting a complete application being aYvdre that upon fiilure to do so, the staff has no altemaGve <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 eithar 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 a�d 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 bs issued. <br /> Applicant's Signature: � �nN ��•��/�s Date: �l��3/(� <br /> last Updated: 05-Oa-2009 <br /> ti��:a6pd 9Z9b6bZZS6�ol .�pd :wo.a� �Z�60 aZaZ-ZZ-d3S <br />