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���v� ��' �'���``�� �ERMIT TYPE: �,
1335 Brown Rd. South • P.O �s�:�x nr,' � Permit Number: T _�. �
Crystal Bay, Minnesota 55323 ��'��y�i�`'�
Date Issued:
(612) 473-7357
SITE ADDRESS: ---__ _ _— — :;r-�si,�;E�I tdE �;�t�
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REMARKS: �'��e��%�e. '1�-�l 8– la/J-�o�9/
FEE SUMMARY:
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APPLICANT%PERMITEE SIG� TURE ISSUED BY:SIGNATURE C��
CITY OF ORONO - E LLDING PERMIT APPLICATION
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Total Fee: $ -�� ��' Date Received:
` �- - ��� Date Approved:
Entered By:
,
- Permit#: ��� �
AI,L INFORMATION MIIST BE SUBMITTED IN FIILL BEFORS PLAN REVIEW WILL BE STARTED
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THE APPLICANT IS: (circle one) OWNER or CONTRACTOR
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JOB SITE ADDRESS: - -'�� `�Y��'�CG /�� r ��- _ ZIP: -� � `3 `
(work) 7 T�' ����
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N�ME OF OWNER: )�-�13 l� W ` 00� - � PHONE: (home) 4 3 f - (, 5�,��
MAILING ADDRESS: �j li J ��O�.E � ►Yr � � �� CITY: �� �ll�'�'`�'e ZIP: ,J�^3 �� Z_
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ONTRACTOR: `� e � � PHONE:
MAILING ADDRESS: CITY: ZIP'
TYPE OF WORR: New Addition Accessory Structure Move
Demo Remodel/Alteration Renovate Land Alteration
PROPOSED WORR (describe in detail) : ��C�,�� S ►�Dc.��U''� ('9 v� �t�C?�
� ���� - ��/-�-��/�/
STORIES: SQ. FEET OF EACH FLOOR:
TO. OF BEDROOMS: GARAGE STALLS: ATT. DET.
'CIMATED CONSTRUCTION VALIIATION (excluding land) : $
reby apply for a building permit and I acknowledge that the information
e is complete and accurate; that the work will be in conformance with the
�ances and codes of the City and with the State Building Code; that I
stand this is not a Fermit and work is not to start without a �ermit; and
he work will be in accordance with the a��rove� plan.
" _ .. _ ,
T'S SIGNATORE: ''�v�`� i ,��'� DATE: �� �- �����
tPleas� fill out the rev se ide of this form)
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- � -f �iONO
CITY of O
Post Office Box 66•Crystal Bay,Minnesota 55323•Municipal Offices
•
� _ � A ; On the North Shore of Lake Minnetorcka
DATA_ PR�VACY ADVISORY
In accordance with M.S. 15.165, "Rights of subjects of data", we
would like to inform you that your request for a permit or license
from the City of Orono or any of its departments may require you to
furnish certain private or confidential information.
You are notified that:
1. The information you furnish will be used to determine your
� qualification for the permit or Iicense requested.
2. You may refuse to supply data, but refusal may require that
the City deny the permit or Iicense.
3. The information may be shared with other local, state or
federal agencies to the extent necessary to process the permit or
Iicense.
4. If your requested permit or license requires Council action
to approve, some information may become public.
5. You have certain rights under M.S. 15.165 to review private
data on yourself.
6, Your full name, and date of birth are required to process
this application or permit.
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First Middle Last
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Address
'��v���Ye �`��' .�-5 31� -- -
City State Zip
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Phone
I understand my rights as stated above.
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ignature'
BUILB[NG&ZONING—473-7357 • ADMINISTRATION 8c FINANCE—473-7358 • PUBLIC WORKS—473-7359
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