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City of Orono cJv\ M4/ 0 <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) /5'2.50 <br /> Mailing Address: Permit number: J010' 00 4r11 <br /> Qv OPO Box 66 <br /> IS1\ Crystal Bay, MN 55323-0066 Date received: 8/Sf/0 <br /> . ._ _ Received by: /�qCC <br /> �� eiti✓> Street Address: J <br /> �:es �, o~ 2750 Kelley Parkway Plan review fee: aD(O —00 l0 7L <br /> .<4'OA <br /> Orono, MN 55356 g <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: .5 0d Oro' o 0 r . f-c L S <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? I I Yes (J to <br /> If 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 INFOR ATIO <br /> Name: ��� e_.,r e.,2 (',)��j5 c_0(A3n,e. <br /> State License# Expiration Date: <br /> Phone: (o ice . /2_ i Itai7, I <br /> Mailing Address: _ Cit : 's r ZIP: c <br /> Contact Person: Applicant is: Contractor / 'omeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: � <br /> Name: �-4-C L) 'l, W he__6 c-- <br /> Phone <br /> Phone (day): 9'S ��1? 760e <br /> �� Y <br /> Address: L�--'UC1 O o 'TO D ,--,c-A„,-,1 City: --cj„k0' ZIP: S'-`<- c <br /> Email and/or Fax .S71--e k/L.� t ,c -'0 ,b Sd-, LL £u <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ' MCWD review&permits <br /> ❑ Door(s) ` Remodel ❑ Water Damage <br /> `\ Minnehaha Creek Watershed District(MCWD) <br /> ❑ 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 Damage www.minnehahacreek.orq <br /> Overall Project Description: 1 ?CA*1 laE 't-O t_Q_Q. 00 <br /> Estimated Construction Valuation of Project (excluding land) $ /O O <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 to either the public or the subject of the data. Our <br /> purpose and intended use of this inform-tion is to annually upd e/6ur records and records of other governmental agencies <br /> re•uired b law. If ou refuse to sus.I he infor• ation, t - a••licatlor ma not be issued. <br /> 1: 4r .,-MEIlr <br /> Applicant's Signature: Date: /Q <br /> Last Updated: 05-04-2009 <br />