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JUN/29/2�'S;��ION 1 C; 3� P�I Elder Jones Bui lding rAl No, 9�2 8��'. 4909 P, 002 <br /> � Gity of Orona <br /> Building Perm�t Application for Ir�fiernal Work <br /> (windaws, doors, siding, re-roof, etc.) <br /> ��-� MallingAddrRss: Permit number ^ � � �' � <br /> �.g,O� Pa Box 66 . - <br /> _'" � Crystal C3ay, MN 55323-0066 �ate receivad: -, � 1� <br /> �0���,?"��. � Received by: � .V� <br /> ` � Streef Address: <br /> \a '�'A�^��?� � 2750 Kelle Parkwa � —"-"— <br /> � .' �`'7�� S`' Y Y Plan re�iew fee: <br /> � ��': �, G � <br /> � ''�t!?��"Y��9 Orono, MN 55356 . <br /> �s�'�s���'� <br /> �=�� 7otal Fee: � � � -�� <br /> Main: 952-249-4600 Fax: 952�249-4616 vwvw.Ci.orpn -,,,Q,mn.��s <br /> � This application form must be completed in full and alf required information must be submitted. <br /> Incompfete appf€cations will be rettErned. (Pleass print) <br /> GEN�RAL INFORMATlON: L / <br /> Job Site Address' � � �� �t') Cj C1 l� [,.1 t� u (� O <br /> Wifl this be a Parade of Homes, F�emodelers Show se Home or other Display Home? Yes � No <br /> If yes,a specral avent permit is requD�ed w/th Police Departmant and Gity Council approval 60 days prlor to the event. Shuttle 6us servfce wi/l ba <br /> rBqulrad unless app!lcent demonstrates sufficient an-sif9 p��king!S aval/t�b/e. Non-permiHed events will noE be a!low9d. <br /> CdNTRACTOR/APPLICAiV7[IV�OF2MATIOt�[: <br /> Name: �Sa �3�15 • LbY7 <br /> state �icense� � � '�HD At-Home Sezvice, Tnc, ���, <br /> Phone: 269Q Cu�-r�berland Pkvcry, Ste 30U (cell) <br /> Mailing Address: .Atlanta, GA 30339-3913 ZIP� _ <br /> Contact Person: �,ic#CR26$2S7 Ph. 763/542-$826 �omeowner �c��ia o�e� <br /> �mail and/or Fax� <br /> PROPEf27Y OWN�R 1N�ORMATION: <br /> Nan,e: I� � 1' �)' r /1 I Ci �c Cfi a r 11 S ----- <br /> Phone (daY)� SI S� 3 g 3 • s s 3 � c��v:u.;o.y x a-��d z�P: 5 S 3 � 1 <br /> �ddress: / 4 � O �t1 � cl v i.,e, e d ��� Q� <br /> Email and/or Fax �_ _,_ <br /> PROJ�GT INFORMATf4N: - - <br /> � Type of Project: i i Any earth movemont may require <br /> MGWD review&perrr�its <br /> ❑l7oor(s) ❑ Remodel ❑Water Demage <br /> � Minnehaha Creek Watershed District(MCWD) <br /> Window(s) Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑Sidiny ❑ Restoration ❑Othe1':,(speCify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-3-oof ❑ Fire Uarr,age www,minnehahacreek.orq <br /> Over'2!I ProJect l7escription: rp ��(��(��„� ('a Q �Q;� 0 r � b j <br /> Estimafeci Construction Valuation of�'roject(excluding land) $ '� � � '� <br /> �.w..._ , .—..... <br /> APPLICANT ACKNOWLEDG�M�N7: <br /> . Agrees to provide all information required or requested by the Buif(ling Denaftmen[; <br /> • Gertifies that the information supplied is true and CorceCt to the best of his/her knowledge. The applicant reco�nizes that they <br /> . are Solely resppnsible for submitting a complefe applic�tion being aWate that upon failure to do so, the stafF has no altern2tive <br /> t�ut to reject it until i?is com�fete; <br /> j • SOme Or all Of ihe information that you are asked to provide on this applicatiorl is classified by State law as either private or <br /> confidential. Private data is information whieh generalEy cannot be givcan to the public but can be given to the subjeci of thA <br /> d8ta. Confidentlal data is information which generally cannot be given to either the publlG or the SUbject of the data. Our <br /> purpose and intend2d use of this information is to annually update our records and records of othe� govemmental agencies <br /> r� uired b law. If ou refuSe io SU�p1Y tl�e infpnnation,the application may not be issued. <br /> ApplicanYs Signature: � Date_ <br /> G � l � fl � <br /> � <br /> Last Updated: 05-04-2Q09 <br />