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. � City of Orono BuiNding Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: .¢,�,�. PO Box 66 0 „4 O Crystal Bay, MN 55323-0066 Date received: ,,.�,> a, +Q�`J,�� ':� a, Street Address: Received by: 's',�, ,� R`0 �ti 2750 Kelley Parkway Plan review fee: l � 1�� v Orono, MN 55356 `�kESHo� --� Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This applic�tion form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: / /f V,� � �� Job Site Address: p� / 7 0 P/�O 5 p� C �f !`1' Will this be a Parade of Homes, Remodelers Showc se Home or other Display Home? ❑ Yes ❑ No /f yes,a specia/event per it is required with Po/ice Department and City Council approva160 days prior to the event. Shutt/e bus service wi//be required un/es applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. CONTRACTOR I APPLI ANT INFORMATION: Name: THD At- Home Services, Inc. `1a �•,, State License# �T` � 3ys - �0�7 Phone: j 2690 Cumberland Pkwy, Ste 300 (cell) Mailing Address: � Cumberland Office Park ZIP: Contact Person: a Atlanta, GA 30339-3913 lomeowner (Circle One) Email and/or Fax: Lic#20268257 Ph. 763/ 542-8826 PROPERTY OWNER I FORMATION: �; Name: p U /'Cl ! ( Q /� C/�1,G Phone(day): ? ?0 • 6 7 S 5• 3 � � Address: � �/'C� Cit : Wf! A�4� ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: � Any earth movement may require MCWD review 8�permits ❑ Door(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) �Window(s) �Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven, MN 55391 ❑ Siding ❑ Restoration ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑ Re-roof Fire Damage www.minnehahacreek.orq Overall Project Descript on: W i A d�01�J� �`f A CI M�n //I Q /� in 0 /I)/!1 � Estimated Construction Valuation of Project(excludmg land) $ �// � APPLICANT ACKNO LEDGEMENT: • Agrees to provide al information required or requested by the Building Department; • Certifies that the inf rmation supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsi le for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it'is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies re uired b law. If au refuse to su I the information,the a lication ma not be issued. ApplicanYs Signature: �J Date: � � ` � 0��/ � Last Updated: 05-04-2009