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JUN-30-2011 06:37 From: To:19522494616 Page:2�2 <br /> � <br /> � <br /> City of Orono <br /> Buiidiu�g Permit Application for Internal Work <br /> (windows, doors� siding, re-roof, etc.) <br /> Mailing Addr�ess: permit number. "� � G <br /> O�Q�,O PO Boz 6B <br /> Crystel Bay,MN 55323-006B Oat�recefved: <br /> � � SUeet Address: Received by: <br /> 2750 Kelley Parlcway plan review t�e: <br /> ����° Orono,MN 55356 <br /> Total Fee: �� '} -7 ��l� <br /> Main: 952-249�600 Fax: 852-248-4616 www.ci.orono.mn,�� O` <br /> This application form must be completed in full and all requlred information must be submitted. <br /> Incomplete appllcatEons will be returned. (Please p�n� <br /> GENERAL INFORMATION: <br /> Job Site Address: �� � � � <br /> Will thls be a Parade of Homes, Remodele�Showcase Ho e or other Display Home? Y�s No <br /> 1/yesy a sr+eciel everM pennit is requlred with Polioe Oepa�tn+eni and Ciy Council eppioval 60 days prhor to the event. SAultle Dus s c�wU!be <br /> requiied uNess epp6can!demonsb�tes sutficient on,s�7e perfring is evailable. Non pelmitted evenl8 will not be allowed <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: /d/ <br /> State License# Expiretion Date: �j�?/�a <br /> Lead Certiflcadon Number. Explration Date: � <br /> (for work on homes that we►se consbu�ted prfor ro 1978 <br /> Phone: / . , � (o�ce) (cell) <br /> Mailing Address: / �j y City: ZIP: �� <br /> Contact Person: �¢�„/61�� j,�,l�,��/� _ Applicant is: nVa / Homeowner �ciR►�o�a� <br /> Email and/or Fax: �/��g� ����,,��.�hg��¢,'�r�. Goy,e7 <br /> PROPER7Y OWNER INFORMATION: <br /> Name: <br /> Phone(day): • � <br /> Address: /��9� A,�. �Y �/V� ZIP: �j�l� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of ProJect: Any earth movement may nqu�re <br /> ❑Daor(s) ❑Remodel ❑Water Damag� MCWD revlew 8 permlts: <br /> Minnehaha Creek W�tershed District(MCWD) <br /> ❑Window(s) ,�� ❑Repair ❑Slorm Damage 16202 Minnetonk�Bbd <br /> g ❑Restoration ❑Other:(specify) Deephaven,MN 55391 <br /> []Sidin \�� Phpne: 952�71-0590 <br /> �Re-roof �;�'� 0 Fire Dam�ge F�ax: 952-471-0882 <br /> � www.minnehah��r ek.orn <br /> Overelt Pro)ect Descri tlon: B�� - � <br /> Estlmated Construction Valuatuon of Project(excluding land) $ �� c��. �-I <br /> � <br /> APPLICAIdT ACKPIOWLEDGEMENT: <br /> • Agrees to provide e�l infiorm�tion required or requested by lh�Building Department; <br /> . Certifies that the Intortnatloro supplled is we and correet to the best of his/Ner knowledge. The applicanl recognizes that they <br /> are solety responsible for submitting a complete appllcatlon being aware that upon fallure to do so, the slaif has no altemative <br /> but to rejecl fl untfl It Is complete; <br /> • 8ome or all of Ihe intormadon that you are asked to provide on this application is classified by State law as eilher prlvate or <br /> confidential. PMvate data ia lnlormaGon whfch generally cannot be glven to lhe public but can be given to the subjed oi the <br /> dats. Confidenbal date is infnrmalion whlch generelly cannot be givan to elther the publlc ot the subJect of the da�a. Our <br /> purpose and intended use oi this Information Is to annually update our records and records af olher govemmenlal agencies <br /> re ulrad law. Ii u ret e u I t �nfa tlon e a Ilcation ma not be fssued. <br /> AppliCant's Signature: � Date: [/��jJ���_ <br />