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APR/16/?015/THU 12: 40 AM FAX No, 952 854 4909 P, 002 <br /> . <br /> City of Orono <br /> Bu�iding Permit Ap�lication for Internal Work <br /> (windows, doors, siding, re�-roof, etc.) <br /> MailingAddress: p�rrttit number. 2�� 'rJ'v� <br /> ���,d,j� PO Box 66 . I t- <br /> � (� Crystal Bay, MN 55323-0066 Date received: �-t �'��v —��J <br /> M��""'� Received by: �I� <br /> � `' a, Street Address: <br /> �,�,��''`�SE oti'`' 2750 Kelle Parkwa —J' <br /> Y Y Pfan reviewfee: <br /> '���p� Orono, MN 55356 � <br /> Total Fee: ' a 2 -� <br /> Main: 952-249-4600 Fax: 952-249-4816 uvwuv.ci.orono.mn.us <br /> This application form must be cornpleted in full and afE required information must be submitted. <br /> Incomplete applications will be refurned_ (Please prinf) <br /> GENERAL INFORMATIOI�(;,� ` Q � � L Q � b� _ O C} <br /> Job Site Address: a! ll <br /> Wilf this be a Parade of Homes, Remodefers Showcase Home ar other Display Horne? ❑Yes No <br /> If yes,a specla/event perm/t/s requlred wlth Pollce Depariment and City Counc;l approva!60 days prior to the event ShutHe bus sa►vice wi4 be <br /> requlrsd unfsss appllcant demonstrates sufflclent on-sfta parking is avalfab/a. Non-paimiYted avents wi0 not be a!lowed. <br /> CON1"RACTOR/APPLlCANT INFORMATION: ������S ,G �y� <br /> Name: THD At-Hpzxae Service, Lac, <br /> State l.icense# <br /> Phone: 2690 Cw�berland P�wy, Ste 30Q (cell) <br /> Mailing Address: A,t�.anta, GA,30339-39X3 zE�' <br /> Contact Person: Lic#CR268257 ph. 763/542-$826 Iomeflwner (Clrcle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER I OR�IA Ti01�:�Q v � � <br /> Name: �� T <br /> Phone(day): fl . 8 q <br /> Address: � v � Ci �d'�ti l"�/o C z�p_ S S 3 � <br /> Email and/or Fax <br /> PROJECT INfORMATION:�- * <br /> Type of Project Ally earth movement may Yequire <br /> � ' MCWD review&permits <br /> boor(5) ❑Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> []Wndow(s) ❑ Repalr ❑Storm DBmage 18202 Minnetonka 81vd <br /> Deaphaven,M N 55391 <br /> ❑Siding . Q Restoration ❑Other:(SpeCify) . Phone: 952-471-0590 <br /> Fax: 952-471-06$2 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orp <br /> Overafl Project Description: i !'i ! Q �! � //1 <br /> �stimated Construction Valuati n of Project(exclud ng iand) � g ,rj S O <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all'informa'tion required or requested by the Building Departmerl#; <br /> • Certifies that the informatipn SUpplied IS tn,le and COt�eCt to the best of his/her knowledge. The applicant recognizes that thay <br /> . are solely respOnsible for submitting a complete application being aware that upon failure to do so, the staff haS no altemativs <br /> but to reJect it until it is complefe; <br /> • Some or all of the information that you are asked to provide on fhis application is cfassified by State faw as either private or <br /> confidentisl. Private data is information which genera�ly c2nnot be glven to the public but can be given to the subject of the <br /> data. Confidential dat2 is information whioh generally cannot be giyen fo either the public or the subject of the daCa, Our <br /> purpose and intended use of this in{Orm&tion is to annually update our records and record5 of othel'gOvel'nmental agencies <br /> required b law. ff ou refuse fo su I the information the a lica'on ma not be issued. <br /> � � � <br /> ApplicanYs Signature: � Date; ��� � <br /> Last Updated: 05-0a2009 <br />