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City of Orono 3"2 <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: Cd//–062 1� <br /> 01 PO Cr Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> i <br /> A Street Address: Received by: yH � <br /> 2750 Kelley Parkway Plan review fee: <br /> r �ss0 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 /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: _Z-S8,_'3- Q/b 6,AC-14 R Z), QiZ o�ln M h,( <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? LJ Yes No <br /> H 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 /> Name: LL e--A i C zJ' <br /> State License# Zo6 38 6r9 Z- Expiration Date: c�3 <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (office) Z Ce St. 86 1,'183 (cell) <br /> Mailing Address: i 13=-13 SFAA-7-o ti AJZ . a P-1 Zv0 CiWji, '6 A( PIU,X-ie ZIP: 3S3�i� <br /> Contact Person: t3iLL W i PLL C--r- Applicant is: n rac / Homeowner (circieone) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: AL Aw:) Lt! z�- 8,sl46 i' <br /> Phone(day): 9,5-2- , 3 7g , 3 g Z <br /> Address: Z6 85 OL"�) 8-Z 14 k D City: 0 120lj 0 ZIP:SS -,k> <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 /> Phone: 9521171-0590 <br /> ❑Re-roof ❑Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.ong <br /> Overall Project Description:jk j)6 '7'y�3fSNc�rdr�. 7v 65m—i Yz 64TY4 Nto4c $tt two- 'A-M OFF,i�C 412&�, <br /> Estimated Construction Valuation of Project(excluding land) $ l- ?.cso, cXJ —' <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 /> required by law. If you refuse to 5upply the information,the application may not be issued. <br /> Applicant's Signature: Date: 3IL`1 "ti <br /> Last Updated: 03-01-2011 <br />