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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: /�— ��
<br /> Og,D,�.O PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> ,� ���. ��;:�, a, StreetAddress: Received by:
<br /> '�, � �� Gti�' 2750 Kelley Parkway Plan review fee:
<br /> L9k�H0¢F' Orono, MN 55356
<br /> -- Total Fee: �/„�
<br /> Main: 952-249�600 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: — , } 1 ��'1 �-� _. ,� , ,i_ � ►l ����, ,-� ',
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No
<br /> ff yes,a special event pennit is required with Police Department and City Council approva!60 days prior to the event Shuttle bus service will be
<br /> reyuired unless applicant demonstrates suff�ient on-site parking is availa6le. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: C-�1�r"� tr:���c_` (.C��•t`';iY�.i�_-t�,"�► � � 1k'1�.
<br /> State License# ;�L �,.5 � 3� ,� Expiration Date: �;3%;�j �;��,� �
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prlor to 1978
<br /> Phone: `��-"3 �:J�] - �,�, �; `'j (o�ce) (cell)
<br /> Mailing Address: c���--� ; � � ��. City: '_iaz:�k���ri -c��,� ZIP:;;r���•��
<br /> Contact Person: ,���� �� (�,Y1� �� <i; Applicant is:�Contractor / Homeowner �cir��oRe�
<br /> Email and/or Fax: �r ,.;n � �: i;<: i�,��r ��,F�r„< t;r�:, . c;_�,.7.-- - ic.•-, i,:�� 7 -7� r: 7
<br /> PROPERTY OWNER INFORMATION: ,
<br /> Name: `jC�._ }i (�1"`i i i`.;I u'� :s��:r��
<br /> Phone(day): �j;� , �`C���, ��'j��
<br /> Address: llrl� P\ . IA;r�Y� ���--�,�:c- City: ���[,i:_s�j� ZIP Jc::y�.��
<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 8�permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd
<br /> ❑ Siding ❑ Restoration ❑Other: (specifyj Deephaven, MN 55391
<br /> Phone: 952-471-0590
<br /> .�Re-roof ❑ Fire Damage Fax: 952-471-0682
<br /> www.minrehahacreek.orq
<br /> Overall Project Description: �t.� ,.�c-•`,.; �� ._�'�r:,c:._ �c��` �
<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 t su I the information,the a lication ma not be issued.
<br /> � ' r
<br /> Applicant's Signature: % '��- ;- �� �• ' �y�--�' Date: r���f/�
<br /> Last Updated: 03-01-2011
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