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City of Orono
<br /> Building Permit Appiication for Internal Work
<br /> � ' � (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number:
<br /> O�v�,�0 PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> I.� �' ^�+'' �, Street Address: Received by:
<br /> �:.
<br /> �'�n ' ^°�� ���' 2750 Kelley Parkway Plan review fee:
<br /> L�ESH04'� Orono, MN 55356
<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 /> fncomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION: �
<br /> Job Site Address: �- � � G' /L� , G�c..-u. . �v-�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No
<br /> If yes, a special event permit is required with Polrce 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 rs available. Non-permitted events will not be allowed.
<br /> CONTRACTOR I APPLICANT INFORMATION:
<br /> � ,,.
<br /> _ , , �.
<br /> Name: T���r.�i.L, �. r � �„c,..�'l (s--�-yR,..,�t.�.,.����` �� n.r,
<br /> State License# ,Z � .�r-�-1 �f��(� Expiration Date 3 � �/,�
<br /> Lead Certification Number: Expiration Date: ' r'
<br /> (for work on homes thaf were constructed prior fo 1978
<br /> Phone: (office) (cell)
<br /> Maifing Address: �� 7 � ',� r' . �,�,,�. `') City: :4y. ,,,4 � ZIP: �5-�
<br /> Contact Person: � � � �' Appficant is: Contrac�o7�1 Homeowner �c�r�ie o�e�
<br /> Email and/or Fax: G� �-:�y�S- - ,�-/S G'+ ` �
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: _ ;�.`,..-t ���.,v�.a..�t �.�c.-.-,�t,GA
<br /> Phone (day): �, � Z - '�.,� � _ d�=7 ct
<br /> Address: t�, � '^-r
<br /> � l�;'�% � � ,,c�..h...::��.t���.-.P..l� {�../►..t�;,wi City: � �..y,�.,.- ZIP: �_�-j (� y
<br /> Email and/or Fax �� ,�—� 1- y� �- - �,! ,��-Z,'
<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 ❑ Restorafion ❑ 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: J ,� ,,,,,��,
<br /> Estimated Construction Vafuation of Project (excluding land) $ -�"'�C C�
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department;
<br /> • Certifies that the informafion suppfied is true and correct to the best of his/her knowledge. The applicant recognizes that they
<br /> are solely responsibfe 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 ctassified by State law as either private or
<br /> confidential. Private data is informafion which generally cannot be given to the public but can be given to the subject of the
<br /> data. Confidential data is information which generalfy 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 fication ma not be issued.
<br /> !
<br /> Applicant's Signature: "'""���Z,,��,,.�,,,� �,:��� � Date: cS� ,f/ ,�" / f
<br /> T� . � �
<br /> LastUpdated: 03-01-2011 "
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