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of <br /> 5h City Orono <br /> • <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address. Permit number: 4:7?9/0- CO 58 <br /> ..,0� PO Box 66 <br /> o •O\„ Crystal Bay, MN 55323-0066 Date received: '-/- 01,3 /D <br /> "`-_sem Received irl <br /> ' I Street Address: by: <br /> �.4 I ,,,A i•" o~• 2750 Kelley Parkway <br /> • Orono, MN 55356 Plan review fee: <br /> L`�kESHo `�v <br /> -- Total Fee: `7 i t <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: ! b 5 0TU14Z) C &i , ( �� (? .�63 y <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home?Home? 7I Yes If yes. a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP ^ICANTO 1NF ATICoN: I ,` ., <br /> Name: ej et 1 _ l-C.�W <br /> State License # Expiration Date: <br /> Phone: .offic ) (cell) <br /> Mailing Address: (Q S ` �M1 �'�� --1�r f\co- `� City: IP: <br /> Contact Person: t-C/N Applicant is: Contractor Homeown (circle One) <br /> Email and/or Fax: C y_ 6 e LH <br /> PROPERTY OWNER IN OR. ,ATION: <br /> Name: . �61,11A 1--AN Qi <br /> Phone (day): C 7_ , i - _._ <br /> Address: S 0rc�� � <br /> (ILc r City: C�✓e/ln c ZIP5��� <br /> Email and/or Fax e_( 1 L ,Oe. fV oN1 Cu,( Ly-y) <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> 'Door(s) ^Remodel ❑Water Damage <br /> ,t Minnehaha Creek Watershed District(MCWD) <br /> Zi 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 Dama e www.minnehahacre� LA <br /> Overall Project Description:al ./O J find it - k vV r� //I 1010 <br /> Estimated Construction Valuation of PPrrolect (excluding land) $ 16 ou ' c /i f„pr 're <br /> APPLICANT ACKNOWLEDGEMENT: SYt L d!.. <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 upply the information,the application may not be issued. <br /> Applicant's Signature: ' 09 /4. 1 Date: i.1T <br /> Jpdated: 05-04-2009 <br />