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�� ��x ` -� <br /> , . . _ �'� ��� ���?, 0� <br /> City of Orono <br /> Building Permit Application for Internal Work������ <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: a 0/D — Op/c� <br /> �.�0,�. PO Box 66 ' <br /> x Q Crystal Bay, MN 55323-0066 Date received: - - <br /> •�. <br /> � " Received by: <br /> a � �', a.� StreetAddress: <br /> titi 2750 Kelle Parkwa � Q <br /> ��l �~�G Orono, MN 55356 y ab�o�A6i`fc� P�an reviewfee: _ . J r.� <br /> 9kEsxo4` <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: ���� �����T �D ���'��' n��✓ <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 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 INFORMATION: <br /> Name: ��FKk�-��/u �{irzrr�s� /,vc <br /> State License# a c�S� 3 3 9�l Expiration Date: 3/�i��� <br /> Phone: �;� ���.�7�7 (office) (cell) <br /> Mailing Address: ',S ;� rc�s��� � �iLK S Cit : ���fi�r� h�� ZIP: 5/�� <br /> Contact Person: i fl�? ��ST Applicant is: ___ / Homeowner (Circle One) <br /> Email and/or Fax: ��5�.��'ncrric�,s�•n�e� <br /> PROPERTY OWNER INFORMATION: <br /> Name: j�n? � ,I},�R�y �%�iF�r� � <br /> Phone (day): <br /> Address: ?7�5�-,���.r�nv;�D City: G'�cti�o ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Z �y Any earth movement may require <br /> ��,,�r���� � MCWD review 8�permits <br /> ❑ Door(s) �'Remodel ;J.v�"� ❑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: ir���o,�,�-� jj���,�,h <br /> Estimated Construction Valuation of Project(excluding land) $ /',�,���-v <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 hislher 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 lication ma not be issued. <br /> ApplicanYs Signature: f ��a��� � Date: `3�''�r' <br /> Last Updated: 05-04-2009 <br />