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SEP/26/2014/FRI 02; 00 AM Elder Jones Building FAX No, 952 854 4909 P, 002 <br /> . R, <br /> - ' City of O�-ono <br /> ' Buildir�g Permit App�ication for lr�terna! Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: permit number: / . / d3 <br /> O�,d,j�.� Pp Box 66 <br /> CrysCal Bay, MN 55323y0066 Date received: -�.4- <br /> a �;� .��`,� � StreetAddress: <br /> Received by: <br /> �, .��� ` � 2750 Kelley Parkway I'lan review fee: <br /> �e��$�p�.� Orono, MN 5535fi <br /> Tot�l Fee: �j�' � <br /> Main_ 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us /� <br /> This applicatiort form must be completed in fufl and aA required information must be submitted_ <br /> Incomplete applications wlll be returned_ (Please print) <br /> G�N£RAL INFORMATION:/� 5 � S� C� �� Q � <br /> Job Site Address: � lr►�U U <br /> WiEI fhis be a Parade of Homes, Remodelers Showcase Home or other Display Hame? ❑Yes No <br /> If yas,a specia/event parmit is repuirad wrth Pollce Department and City Council approve/60 days prlor io ihe eveni. Shums bus service wiJl be <br /> ,�quired unless applicant demonshstas sufticlent en-s�'te parking is availab/e. Norrpermltted events w!!l not be sllowed. <br /> CONI�I'RACTOR I ApPLICANT INFORMATIpN: <br /> Name: f�� 3�S-G oy7 <br /> State �icense.# Tl-�D At-Home Service, Inc, o ' <br /> Phone: 2690 Cumtier�and,Plcvvy, Ste 300 ceu <br /> Mailing Address� Atlanta, C�rA 30339T3913 Z�P= <br /> Contact Person: _ LiC#CR268257 Ph.763/542-$$2b lomeowner (Clrcle one) <br /> Email and/or Fax: <br /> PROPEi2TY OWEVER FORMAT'ION: <br /> Nam e: b %i� d �L t ( <br /> Phone(day)� Y9 +�" s' n � ; t�uG �4TG <br /> Address: �0 0 0 Ci ZIP: �5'3 Q / <br /> Email and/or Fax <br /> PROJ�CT�NFORMATlON: <br /> Type of Proj�ct_ Any earth movement may require <br /> MCWD review&permits <br /> ❑Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek WateBhed District(MCWD) <br /> indow(s) Repair ❑Storm Damage 18202 Minnetonka Bivd <br /> � Deephaven,MN 55391 <br /> Siding ❑Restoration ❑Other:(specify) Phone: 952,471-0590 <br /> Fax� 952-471-0882 <br /> ❑Re-roof ❑ Fire Damage www,minnehahacreek.or <br /> Overall Project Description: /(.��11 ea(,�.W �`� f(y ��Yj s/� �l� �k� 1 i� � � n��j <br /> Es#imated Construction VaEuatYon of Project(excluding Iand) $ ;,� ' <br /> AP�UCANT ACKNOWLEDGEMENT: <br /> • Agrees to provide af!information requirad or requested by the Building Department; <br /> • Certifies that the inforrrlation Supplied is true and correCt to th2 be5t Of his/her knowledge. The appUCant recognizes that thgy <br /> are sol�ly responslble for submiYting a completa appliqtion being eware that upon faiiure to do so, the staff has no altemative <br /> bUt to fejeCC it untii it is carnplete; <br /> . Some or all of Ihe information that you ar@ asked to provide on this application is Classtfied by State law as eithe�p1'ivaTe Or <br /> eonfidential. Private data is Information which generalty cannot be gfven to the public bu# can be given to the subject of the <br /> data_ Confidential data is inFormation which ggneCdlly Cdnnot be given #o sither the publiC Or the subject of thA d2t2. OUP <br /> purppse and intended use of fhis informatiqn Is to �nnuafly update our records and teeords of other govcmmental agencies <br /> re uired b laW. If ou refuse to su I the infoYmation the a plication ma not be i55ued. <br /> ApplicanYs Signature: ��� Date: 1 � � ` �/ <br /> �ast Updated; OS-04-2009 <br />