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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: ���� -�d C! <br /> ��� PO Box 66 <br /> � ^. 'Q� Crystal Bay, MN 55323-0066 Date received: �v �/C� <br /> ,� �`��"��-�;�, s,l� StreetAddress: Received by: <br /> '�',F, '� °"�� �ti 2750 Kelley Parkway Plan review fee: <br /> ��kESHOg� 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 /> GENERAL INFORMATION: 1 <br /> Job Site Address: � �� ��_; �\�'J� �-�� 'u�� v ��-� C� U' � <br /> Wilt this be a Parade of�omes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If 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 sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> � <br /> Name: ��__1 �_� ��-�,_��.�y°� t, <br /> State License# i v j�c.i Expiration Date: <br /> Phone: �� i�.— �;�;� �j - '��� �fs� (office) (cell) <br /> Mailing Address �Gli.t; ����<<�� 1�(��� City:��{,�(r'•.� �s "(y�� ZIP:<,'y 1E=. <br /> Contact Person: Applicant is: Contractor / Homeowne� (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> "�' ..� �,, <br /> Name: .� c, v� 1��v,C_.1�� �i ��.i; ✓� <br /> Phone (day): � t- - ,. �!_. �v�p � ( � <br /> Address: /:�.,�"�� /�'i�r�'�, I��'Gr� ��' City: r', ;����� C�� ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> �Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: ,- ' I " } J <br /> - - V L r'v-i'... r:_ V t ,I .6. ` � i�C�' l,^ �`�,li�`�t l%� �L:t��'i.^x!f �-�.`1 L"����E, <br /> Estimated Construction Valuation of Project(excluding land) $ �'; , L�(:, � � �"J <br /> ��' <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 /> '� i / <br /> ApplicanYs Signature: �� / Date: ,�t% � � l � <br /> , <br /> / <br /> LastUpdated: 05-04-2009 � <br />