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. � City of Orono <br /> , � w Building Permit Application for internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Add�ss Permit number. <br /> O�D,�.O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> �. Streef Address: Received by: <br /> �',�,� ' ����' 2750 Kelley Parkway Plan review fee: <br /> ���o�. Orono,MN 55356 <br /> Totai fee: <br /> Main: 952-249-4600 Fau: 952-249-4616 wvrw.ci.orono.mn.us <br /> This application form must be completed in full and a11 required informati�n must be submitted. <br /> Incomplete applications will be retumed. (Please print) <br /> GENERAL INFORMATlON: <br /> Job Site Address: �" �rr'i'� S�a�- � ��11�c- �; z�-�a. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other isplay Home? Yes o <br /> If yes,a specia!event permit is requiied with Police Department and City Councr(approva/60 days prior to the event. Shuttle bus service wrll be <br /> requi�d un(ess applipnt demonstrates su/ficient on-site parking is available. Non-peimitted events wi!!not be allowerl. <br /> CONTRACTOR/APPLICA T I FORMATIO : � / �- <br /> Name: I�'1G..-�-� l�e,��c� ��r�,^ `�'.�-` ��S-f ftN-.a"i[n'� �_.� �c�+.•fJ Tr')�-- <br /> State License# �,p 3 7 S��� r Expiration Date: .�-3/ -a Ol / <br /> Phone: �lo:,- SS��-//On (office) f.�ia-• 3 9- //8'/ (celQ <br /> Mailing Address: �i SS sc1�` c c�e:r: Ci : �:�.�c�., �/�s ZIP: S �,�, <br /> Contact Person: /J� �:�. Applicant is: ontractor Homeowner tcxae o�e� <br /> Email and/or Fax: /r!���,c�, �D, s�,�ir�¢,-{- c�7 . ��vy„� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �r'i S ���.,.��.Q <br /> Phone(day): L�I� -3 9(o -- (o i 7� <br /> Address: :3otSl„ N���/, „S�c�,.e !� r r vc, City: [,.t)�t„ zl,�� ZIP: �S��/ <br /> Email and/or Fax ;//{3=z �� � r►oc:l1 s%. ��w►-� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door s MGWD neview 8 permits <br /> ( ) ❑Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> �ndow(s) �Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> �`iding ❑Restoration �Other.(specify) Phone: 952-471-0590 <br /> ❑Re-roof ��p;3-�-� ,��, Fax: 952-471-0682 <br /> ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: �?� ' � , �Jc�r(� " S -� s�- -p�c_ � <br /> Estimated Construction Valuation of Proje t(excluding land) $ /g � , �7O <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Qepartment; <br /> • Certifies that the information supplied is true and correct to the best of hislher knowtedge. The applicant recognizes that they <br /> are soiely responsible far suhmitting a complete application being awane that upon faifurie to do so,the staff has no aftemative <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 dassified 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 subjed of the data. Our <br /> purpose and intended use of this infoRnation 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 liqtion ma not be issued. <br /> ApplicanYs Signature: Date: ���"�� <br /> Last Updafed: 05-04-2009 <br />