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<br /> City of Orono -
<br /> �
<br /> G } Building Permit A lication for Internal Work �
<br /> � pp �
<br />�', (windows, doors, siding, re-roof, etc.) z;;,
<br />��� Mailing Address:
<br />�� �'.+0.� PO Box 66 Permit number: �
<br />�" C stal Ba MN 55323-0066 �
<br /># . � . Q rY Y, �. Date received:
<br />�� �a ���3��s;'�� �,� StreetAddress: Received by: �
<br />�5 �'�n ' �'� �,ti�' 2750 Kelley Parkway Plan review fee: �
<br />�� t`�gESKo�`'� Orono, MN 55356
<br />� Total Fee:
<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. �
<br />��'• Incomplete applications will be returned. (Please print)
<br /> �' GENERAL INFORMATION:
<br />�: �
<br /> r�� Job Site Address: �;55 y� Ly i�;r ��"`�
<br />��� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No
<br /> !f yes, a specra/event permit is required with Po/ice Department and City Counci/approva/60 days prior to the event. Shutt/e 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 INFORMATION:
<br /> ���
<br /> Name: ��P�s i��t-.-.s.�n �-
<br /> State License# 3 7/ � Expiration Date: 3 /3/ �zc, i v ��
<br /> Phone: 's 2 0 0 office �: i 2 � t ' � cell �
<br />�fj Mailing Address: �.� Q � ,�� k {���� City: �� � .LS-�_ZIP� 5�3 �7
<br /> �- Contact Person: k-�/t Sf,�,.�,#� Applicant is: �on�r��br_==� Homeowner (Circle One)
<br />``" Email and/or Fax:
<br /> a �rles Cu' cl.r;6�a-�u;Y��. c-��
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<br />���':
<br />�`� PROPERTY OWNER INFORMATION:
<br />�4.:::
<br /> Name: L7l-,,.s� �-!a I"�v r�-L,
<br />��,, Phone (daY): °�s 2 ��� «��
<br /> a r, Address: �SSy C�,r�� Av-c Clt : (�d'M ZIP� �� :3��
<br /> Email and/or Fax
<br /> yn,2:-:
<br /> PROJECT INFORMATION:
<br />,`. Type of Project: Any earth movement may require �
<br /> ❑ Door s MCWD review&permits
<br /> ( ) � Remodel ❑Water Damage
<br />� Minnehaha Creek Watershed District(MCWD)
<br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br />�
<br /> ❑ Siding Deephaven, MN 55391
<br />.Xy. ❑ Restoration ❑ Other. (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> ❑ Re-roof ❑ Fire Damage ��,s y��� www.minnehahacreek.orq
<br /> Overall Project Description: ;��,,,,���:� r�s�-�.Qa.'}� -,�
<br /> �i. Estimated Construction Valuation of Project(excluding land) $ ,��� ��
<br /> �
<br /> ,_ .
<br /> APPLICANT ACKNOWLEDGEMENT: �
<br />, ; • Agrees to provide all information required or requested by the Building Department;
<br /> ir`
<br />�� • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they `v
<br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative
<br /> 4 but to reject it until it is complete; �
<br /> F�•N •
<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 />�=: �.
<br />�. Applicant's Signature: � -� Date: j� 2 � C
<br /> fK;., �
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<br />�'# LastUpdated: 05-04-2009 r . `
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