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� City of Orono (o�b�� <br /> Building Permit Application for Internal Work ����l�� <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: ����� � � <br /> �0,�. PO Box 66 <br /> 0 � O Crystal Bay, MN 55323-0066 Date received: � 7 �� �b <br /> ���'"'- Received by: <br /> � ,� � �. �, Street Address: <br /> '�',�, � �� ������� �ti 2750 Kelley Parkway Plan review fee: � <br /> L9kESH0�`� 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: /y�-5 ��,r l�; r)�-i ✓� C��c�rr c <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ��No <br /> If yes, a special event permit is required with Police Department and City Council approva160 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: Li.�c sf��� �'�s`F�r�; � <br /> State License# /O 7 Expiration Date: 3 .� o <br /> Phone: �6 � –.Sy 76/ office �c«-��–�,F,Z3 cell <br /> MailingAddress: S�6a1 /07� ��n,,�� �c�7X Cit : rr, �c: � ZIP: 'SYS�/ <br /> Contact Person: /�'j,� G� ���:,� Applicant is: ontra / Homeowner �c�r�ie o�e� <br /> Email and/or Fax: �j,,cI:CN �,r�r�r��+,r, co� �c�� - sYy - S�E•6 fi� <br /> PROPERTY OWNER INFORMATION: C <br /> Name: ����c�� G�c�' ���,Q !–�'�r�s <br /> Phone (day): �p 7 y y 6 �?7 b' T <br /> Address: fyis -��L. ,(��-,�.t City: ��o�,o ZIP: <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 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: '���:,rtr: � c:•�,r,< ,r ��� . r :�c r- S c�� - �' <br /> Estimated Construction Valuation of Project(excluding land) ,�C ��� S`� '—' <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 /> re uired b law. If ou refuse to su I the information,the a li ation ma not be issued. <br /> � <br /> / .. <br /> !/����` <br /> ApplicanYs Signature: �� � � - Date: Q <br /> Last Updated: 05-04-2009 (', � �j �S��,�Q //L�.SlJ�/! ���/ �NA'� /NSBs, <br /> ! <br /> � a(�},.1 /Lg1//dt,.J I�� <br />