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JUN-22-2909` 13:51 FROM: 6tileiv. TO:9522494616 P.1 <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> % nO Box 88Mailt Address: <br /> !ermit number. i 9-'O 35'���y4.° Crystal Bay, MN 55323-0068 Date received: (,A 2/oq <br /> Received by: <br /> ,�i'i� ,r Street Address:��` 2750 Kelley Parkway Plan review fee:' N; 4��' Orono, MN 55356 <br /> TotalFee: ://./A. <br /> O� <br /> Main: 952-249-4800 Fax: 952.249-4818 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: /O 7S O Icf Covs7/*/ BAy /00 <br /> W �, o214,5°.it this be a Parade of Homes, Remodelers Showcase Hbme or other Display Home? 0 Yes LJd'N <br /> If yea,a special event permit is required with Police Department end City Council approval 60 days prior to the event. Shuttle.pus service will be <br /> required unless applicant demonstrates sufficient onsite parking is available. Non-permitted events will not be elldwed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Ale-SO eli Con,g4e.c. 111A, <br /> State License# O Expiration Date: 3 3/ - <br /> Phone: .1-.3- G - 2 91 (office) �77- 3C^ ..5Z 72 (cell) <br /> Mailing Address: 3/l 49./-s co rJh S.4,4, Cl : . lire_ ZIP: ..s—s"3 7_2 <br /> Contact Person: /7)i Aes A v.. ori/ Applicant Is: ontractor I Homeowner (Circleone) <br /> Email and/or Fax: /yrj s to-,.s. AA.M s n n 6) 7..,,o . ,.. 11 n.1.1 <br /> PROPERTY OWNER INFORMATION: <br /> Name: arsO i Tc-€ t1r e iuA S+e u v. Ar 4 e( /77 Rti u 7 er. <br /> Phone(day): - •- _0 "0 <br /> Address: /0., _c- o 1 d Cry s I SA?, AJ 4 City:6 trove c.) ZIP: de '"3sr <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 0 Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) 0 Repair 0 Storm Damage 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> ❑Siding 0 Restoration 0 Other:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Re-roof 0 Fire Damage www.minnepahacreek.orq <br /> Overall Project Description: € <br /> Estimated Construction Valuation of Project(excluding land) $ -AAA/, vet <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 supply the information,the application may not be issued. . <br /> /-2Applicant's Signature: ,�f;4(0 ie Date: .06 /6 - .,70 O 7 <br /> Last Updated: 05-04-2009 <br />