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05/19/2014 12:36 9522494616 CITY OF ORONO PAGE 02/02 <br /> M�Y '19/2014/MON 12;56 AM Elder Jones Building �Ak No. 952 854 4909 P, OQ2 <br /> , �. <br /> Cifiy of +Orono <br /> Building Permit Appl�cation for Internai Vllork <br /> (windows, doors, siding, re,roof, etc.) <br /> Me11�+s�aaress: � � <br /> "�"��T PO eox 66 Permit number: � — <br /> �, (� Crystal Bsy,MN 5532�Opfi6 Dete received: � -�j/ <br /> ''� ��� � Str9et Address: R9ceived by: <br /> ��-, ' G�' 2750 Kelley Parkway Alan review fee: <br /> �s8o�' Orono, MN 55366 <br /> Ma��� 95�-249-4800 Fax: 952-249-461 e Total�ee: 9i �l-'l�r <br /> i�OK Ci.otono.mn_us <br /> 7"his application form must b�complatad in full and aU r�equired inforr»atlon must be submitted, <br /> Incorraplete app�ic$tions will be return•d. (P/easo prir�t) <br /> GENERAL INFORMAT1oN: <br /> Job Site Addiress: � �7 0 �/�(� � � RO Q <br /> Will this be a Parade ofi Homes, Remedelers Sho e Home or other�isplay yome? Yes No <br /> !f yes,s Speclel evllnt p�mNt ia ngaul�gd�i�ry pppce Depenment and CKy Gbunpl!4pp�qyp�60 d� �ror � <br /> �ear+ired unfass epp/lcznt demonstra�as m,/fiolenl evr,oi�e p�ing�s avallabla. Non-eimpitte m���/��np�b�,t�o�dervlQ°w'I!Ae <br /> CONTRACTOR�APPLICANT IN�ORMA'fION: <br /> Name: 9S� 3yS- G e <br /> State I.icense# THD At-Home Se�tv�j�e,�c, 7' <br /> Phone: 2690 Cumberland Pk�ovy, Ste 30a ceii <br /> Mailing Address: Atlanta,GA 30339-3913 ZlP: <br /> Contact Person: Lic#CR268257�1�. 763/542-8826 <br /> Email end/or Fax- lomeowner ��,�o„a� <br /> PROPER7Y OWIYER INF� �ON 1 b Q n a <br /> Name: � � �{ � � <br /> Phone(day): s� y 2 � . p � 'I <br /> Address: / v R C' : �Q 7 Q�6 Zlp; "J�'S 3 j <br /> Email and/or Fax <br /> PROJECT INFORMAT�ON: <br /> Fype ot P►oject: <br /> Any opr[�h movement may require <br /> Door{s) �Remodel �W�a�Q�age MCWD review b p4e�� <br /> ❑Window(s) �epA�� ❑StOfm DamOgA Minnehah2 Geek W�ershed Dly�flct(MCWO) <br /> 18202 MirlfletOnka Blvd <br /> ❑Siding ❑Regtpr�ticn ❑pther. s � ��P����MN 55391 <br /> � p �� Phone: 952-471-0590 <br /> ❑Re-roof ❑Fre Damage ��� 952-471-0662 <br /> ���II�Po'ect DesCtiplion: Q �w.minn <br /> �stimabed Constructfon Valuation af F'ro'ect(excluding land $ �X�� � A � <br /> Q O '� <br /> APPLICANT�ACKf�OWLEDGEMENT; <br /> • AGrees to provide all informaGon�qyired or r�equested by tho BUilding Departmer�t; <br /> • Certifies that the infonnatlpe au�rpl(ed is true and con�to the best of his/he��a�Atl9e, 7k�e applicani recognl�aa that they <br /> are solely�p�Sibl2 for submifting a•opmplete application being aware tilat upon failure to do so,tha s�aff'h�,�a��„p <br /> but to�ejact jt until It is Co�tplete; <br /> • 'Some or all of the info►matlon thet ypu 8�e asked to provldo on thig appliCation 1s dslssifietl by State law as elthor pry'�te or <br /> confider►tial. Private dpta is irtformation whlch gena,�ly cannot be given to the public but cen be gfVpn ;o the sub)ect of the <br /> data_ Confidential data fs Informado�vvhtch generally cannot be Qiv�to etther the pubiic or the subjec! et the data. our <br /> purpose end lotended use of this iretorrnE,t;on Is to annually upaate our re�rqs and reoords oF other govemmental agencies <br /> requireC b law, �f ou refuse to su I the Irrfo��q� the a lic¢qOn ma not pe issued. <br /> APP�icaret's Sigr2ature: � � �ate� ��l q ��� <br /> � -�_'_ �_ <br /> i-ast UpdOted: 06-04-2009 <br />