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- City of Orono <br /> � � � Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: Q��� -- �Q$ <br /> O�,i,�,�0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 7� <br /> ��`\�'�� Received b <br /> � � s;-�:a� �, Street Address: y� <br /> �'�,n '� ti�' 2750 Kelle Parkwa <br /> '� � `�G Orono, MN 55356 y Plan review fee: <br /> �kESH�4 <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 /> Job Site Address: j.`��,j � /-�',(./ ��j�' <br /> Will this be a Parade of Homes, Remodelers Showcase ome or other Display Home? ❑ Yes � No <br /> !f yes,a special event permit is required with Police Department and City Counci!approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: � <br /> State License# Z��„?�Z� Expiration Date: 3 �� <br /> Lead Certification Number: ,�,r p�;7��, �,f� Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: Fj( - �7 -rc�;r� �, (office) SJ(��-j� (cell) <br /> Mailing Address: _ �� ��� ��� �� City:�Dl/�-,¢ ��e ZIP: �-�� <br /> Contact Person: (��('�T ���, Applicant is: Contractor / Homeowner (Cirde One) <br /> Email and/or Fax: i7,�� M�� � �-15�: C..^f��' <br /> PROPERTY OWNER INFORMATION: <br /> Name: A-;'��.,.4 i7,4y�L <br /> Phone (day): c�5�, �� ����� <br /> Address: /E1�5� n/�J�1Lf Po:.�( ►�� CitY: �4(q ��,�� ZIP: 5�j�-,<� <br /> Email and/or Fax -�- � ` <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) (�'Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 <br /> Re-roof Phone: 952-471-0590 <br /> � ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Overall Project Description: � - �� - - , <br /> Estimated Construction Valuation of Project(excluding land) $ �}� "-_' <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • 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 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 /> ApplicanYs Signature: � Date: � <br /> Last Updated: 03-01-2011 <br />