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<br /> � - City of Orono ��
<br />, , ,
<br /> � �
<br />,,; Building Permit Application for Internal Work
<br />�
<br /> (windows, doors, siding, re-roof, etc.)
<br /> ���� Mailin Address: �J
<br /> �� g,�,� PO Box 66 Permit number: �'�� -��� � �
<br /> � �1 � Crystal Bay, MN 55323-0066 Date received: ? C�
<br />' � .� ������' �,� Street Address: Received by: �/'�- �
<br /> s <t,�.
<br />��% �'� � �" �ti�' 2750 Kelley Parkway Plan review fee:
<br />�` �`�kEsxo4'� Orono, MN 55356 ,
<br />� � Total Fee: L �� �7�
<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 />�LL GENERAL INFORMATION: .
<br />� ' Job Site Address: ,��.5 �,�/l�� �i�/� G�� �
<br />�;, Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No �
<br />,.� lf yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be
<br />� required unless applicant demonstrates sufiicient on-site parking is available. Non-permitted events will not be allowed.
<br />�:�' CONTRACTOR/APPLIGA T O ATION• , � '
<br /> Name: ��
<br />� State License# j g Z� y Expiration Date: 3/ Z
<br /> t�,� Phone: -� C�—��� office �E���- cell
<br /> e" Mailin Address: �
<br /> 9 c, Cit : ZIP:
<br />'�.�!. Contact Person: pplicant is: ontractor / Homeowner (Circte One)
<br /> ! � Email and/or Fax: .u•� �✓ , .
<br />�' f PROPERTY OWNER INF RMATION:
<br />,, ; �n f �
<br />� Name: �(,�
<br />,��� Phone (day): - - �
<br />;�, Address: � Cit : �/Lbz--i�c.� ZIP:S��.S�(�
<br /> Email and/or Fax �
<br />"°�
<br /><;:�
<br />�S`""' PROJECT INFORMATION:
<br />� Type of Project: Any earth movement may require
<br />�: MCWD review&permits
<br />�� ❑ Door(s) ❑ Remodel
<br /> ❑Water Damage
<br />�: Minnehaha Creek Watershed District(MCWD)
<br />�::y ❑ Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br />� j Deephaven, MN 55391
<br />�„` �Siding ❑ Restoration ❑ Other. (specify) Phone: 952-471-0590
<br /> j Fax: 952-471-0682 �r
<br /> °'1� ❑ Re-roof ❑ Fire Damage www.minnehahacreek.or '
<br />�•� Overall Project Description: � � l � *
<br /> � Estimated Construction Valuation of Project(excluding I ) $ ' �� �
<br />:�� �� ��
<br /> ,;;
<br /> .,
<br />,.{ APPLICANT ACKNOWLEDGEMENT:
<br /> ��, • Agrees to provide all information required or requested by the Building Department; �°
<br /> a4
<br /> i • 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;
<br /> • Some or alf 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 /> � �� � ��
<br /> k+ Aprlicant's Signature: Date: .� / (�
<br /> �. r �>
<br /> ��
<br /> Last Updated: 05-04-2009 �
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