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<br /> � �. City of Orono �
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<br /> . Building Permit Appiication for Internal Work �
<br /> � (windows, doors, siding, re-roof, etc.)
<br /> � Mailing Address: �
<br /> � �,� PO Box 66 Permit number: �
<br /> � / \ Crystal Bay, MN 55323-0066 Date received: '
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<br /> �: a �� �. , �, � Street Address: Received by:
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<br /> �: �'� �j�, �% 2750 Kelley Parkway Plan review fee: �7
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<br /> xEsx�- Orono, MN 55356
<br /> Total Fee:
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<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.
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<br />� Incomplete applications will be returned. (Please print) �
<br /> GENERAL INFORMATION:
<br /> Job Site Address: ��� � ,�� �
<br />' Will this be a Parade of Homes, Remodelers Showcase Ho e or other Display Home? ❑ Yes ❑ No
<br />�;_ If yes, a special event permit is required with Police Department and Crty Council approval 60 days prior to the event. Shuttle bus service will tie
<br /> +f' required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> �
<br />�. �' CONTRACTOR/A�LICANT INFOR ATION:
<br /> Name: ���r��. �h�.rpr�'S eS
<br />� State License# ZO I l0�83 I Expiration Date:
<br /> Phone: qSZ-H f-�d��O'$ office) cell
<br />=" Mailing Address: G l'7s' $�rch �/u Cit : � �� ,-a,- ZIP: Ss 33 I
<br />� Contact Person: Applicant is: rac o / Homeowner (Circle One)
<br />��'I Email and/or Fax:
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<br />� PROPERTY OWNER NFORMATION:
<br />�� Name: �e.���� PGc 5 sow
<br /> � Phone (day):
<br />� Address: /pp �a,��. �,-h„� � c�c,.� City: Q�y�p ZIP:
<br /> " Email and/or Fax
<br />�� PROJECT INFORMATION:
<br />'`�:` Type of Project: Any earth movement may require
<br />�� MCWD review 8� permits
<br />�; ❑ Door(s) ' ❑ Remodel ❑Water Damage
<br /> l�aF Minnehaha Creek Watershed District(MCWD)
<br /> �' ❑Window(s) ❑ Repair ❑ Storm Damage , 18202 Minnetonka Blvd
<br />�; Deephaven, MN 55391
<br /> z� ❑ Siding ❑ Restoration ❑ Other. (specify) Phone: 952-471-0590
<br /> 'r Fax: 952-471-0682 �
<br />�:
<br />,�i�I Re-roof ❑ Fire Damage www.minnehahacreek.ora
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<br />�'°! Overall Project Description: -�-,r�r,�-v�� and /'�foo � aSphc�.Q.�
<br />�,�' Estimated Construction Valuation of Project(excluding land) $ �
<br /> � �p� �,�
<br /> E:' $:t.
<br />�� ' APPUCANT ACKNOWLEDGEMENT:
<br />���I . Agrees to provide all information required or requested by the Building Department; �
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<br />�"' • Certifies that the information supplied is true and correct to the best of hislher 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;
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<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 enerall cannot be iven to either the ublic or the sub ect of the data. Our �
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<br /> +�� purpose and intended use of this information is to annually update our records and records of other govemmental agencies _�
<br /> - re uired b law. If ou refuse to su I the nformation, the a lication ma not be issued. ��
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<br /> ; ApplicanYs Signature: Date:
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<br /> l Last Updated: 05-04-2009 �.,���
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