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. ���1<< <br /> City of Orono <br /> - Building Permit Application for Internal Work <br /> - (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: a���-6 4 7� <br /> Og,�,�.0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: � / <br /> � � Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> l.��Ho�,��' Orono, MN 55356 <br /> Total Fee: , <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us /?g � � <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: �9 Q p�(L"r�K W W p �•Qp•p � (t,d KQ , �N �j �3 s4 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,a specia/event permit is required with Police Department and City Council appmva160 days prior to the event. Shutt/e bus seniice will be <br /> required unless applicant demonstrates suffcient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR 1 APPLICANT INFORMATION: <br /> Name: � �(�� �//J <br /> State License# �"�(e, Q� Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on itomes ti►at were constructed prior to 1978 <br /> Phone: h(i� —'�g(D— '�1 �1 (office) �y�L� �jv1� ' �3�� (cell) <br /> Mailing Address: City:(� � IP: ,�CS ! <br /> Contact Person: �'�} �GqJ Applicant is: on ra / Homeowner �cir�ia or,e� <br /> Email and/or Fax: .���,N� . .�,;�,�,�,� bs ewl �•y r1ri�.b $.l��tv sb,�1 . Ga M.. <br /> PROPERTY OWNER INFORMATION: <br /> ►vame: �(�.0 LE F..P4 L��IS Iyl A. <br /> Phone(day): (o�'Z — 335— Z� G y <br /> Address: �U PAJ�-�13,,�/W O o'17 �.lj p� City:(�IZ.D�J� ZI P: �j�3�L <br /> Email and/or Fax �ue.. . �v�w M,i �o Kua�s �'►..�.vs�f„� . Gd.r.� . <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door s Remodel ❑Water Dama e MCWD review 8�permits: <br /> � � � g Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Siding ❑Restoration ❑Other:(specify) Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof ❑Fire Damage Fax: 952-471-0682 <br /> www.m in ne ha ha creek.o ra <br /> Overall Project Description: p eV •• (1MA5� 1. � Ar <br /> Estimated Construction Valuation of Project(excluding land) $ ��aTC��p� <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 i rmation,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: L � <br /> Last Updated: 03-01-2011 <br />