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<br /> City of Orono h:
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<br /> Building Permit Application for Internal Work , Z� � Y
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<br />�_"; (windows, doors, siding, re-roof, etc.) f-:
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<br /> �� � Mailing Address: Permit number. 0�0��1^� ���
<br />�= PO Box 66 �
<br /> �; /0 Q 1 Crystal Bay, MN 55323-0066 Date received: /Z-/ —O �'
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<br /> k'� �a � �����,�, �,;i Street Address: Received by: _ �
<br />"�" ��'�n � ��"� GtiF� 2750 Kelley Parkway �"`' ' Plan review fee: ���� � �'�''� �
<br /> r�kESH�4'/ Orono, MN 55356 ,��
<br /> -� Total Fee: 4,
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us r�'
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<br /> This application form must be completed in full and all required information must be submitted.
<br />�,y; Incomplete applications will be returned. ( lease print) �''
<br /> GENERAL INFORMATION: � �
<br />��"' Job Site Address: �� L—;J � / �
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<br />��. Will this be a Parade of Homes, Remodelers Sho case Home or other Display Home? ❑ Yes No �
<br />��`, /f yes, a special event permit rs required with Police Department and City Council approval 60 days prior to the event. Shuftle bus service ilf �
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
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<br />� CONTRACTOR/APPL,I,CANT INFORMATION: / " ��
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<br />�o��� Name: I���= f"f"-,��_,�/ l=-'�, ,�l-'� ,��� �..
<br /> s = State License# /��� � Expiration Date:
<br /> Phone: ,� - - �1.�:� � office � �� ��2r - '3(�; � (cell) �
<br />�` Mailing Address: y;� � �, 7��'" _; . City:j� ' � ZIP� ��� � �
<br /> ` Contact Person: " (,_!/ /,.�Z, - 3,��z-�s(�`.�� Applicant is: �Con�a r % Homeowner �c�one�
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<br />�,�. Email and/or Fax: y�.;,z y,'�,� .-,��.,�- �-� �'
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<br />�- PROPERTY OWNER INFORMATIO : S ` �
<br /> :: Name: <��.,� �.;- �l.j s r;�"1 ��
<br />�� Phone (day): ��5,,� -� ��� _ �-s� � , �
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<br />�' Address: /?�v L �o �- Cit � � v;, :> Z�P: - ���� �
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<br />�"; Email and/or Fax �
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<br /> PROJECT INFORMATION:
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<br /> Type of Project: Any earth movement may require �
<br /> MCWD review&permits �
<br /> y�Door�j ❑ Remodel ❑Water Damage �
<br />�' ' Minnehaha Creek Watershed District(MCWD) `
<br /> g• �J Window(�) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd �
<br />� ,�- . Deephaven, MN 55391 �
<br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 "
<br /> ❑ Re-roof Fax: 952-471-0682 ,
<br /> ❑ Fire Damage www.minnehahacreek.orq "'
<br /> Overall Project Description: i�i,:,, ��' ' , ,I ;� , � ' ,�,_, ,,'_ ;�, �N`' , , i
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<br /> Estimated Construction Valuation of Project(excluding land) $ r ��-' � } _ ,, � �
<br /> ��F APPLICANT ACKNOWLEDGEMENT: �
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<br />� ' • 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 his/her knowledge. The applicant recognizes that they �x
<br /> 'n are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative �
<br /> r�' 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 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 govemmental agencies
<br />�'= re uired b law. If ou refuse to su I the information, the a lication ma not be issued. q�
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<br /> ApplicanYs Signature: L `"��! Date: � .� �'� '�
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<br /> Las±Upqsted: 05-04-2009 (/ �=
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