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MAR/06/2013/WED 02: 11 AM FAX No, 952 854 4909 P, 002 . . � t City of Orono Building Permit Application for Internal 'UVork �� 5�T (windows, doors, siding, re-roof, etc.) � . �O� MailiPO Box 66. 3 � DO I J Permit number: O � C ry s t a l B a y,MN 55323-OOB6 Date received: �,, Street Address: Received by. �,� o�' Z750 Keliey Parkway Pfan review fee: � ��o�„� Orono, MN 55�56 Total Fee: Main_ 952-249-4600 Fax: 952 249�616 vwuw.ci.orono.mn.us This application form ust be completed in full and all required information must be submitted. . inc�mplebe applications will be returned. (P/ease print) GENERAL 1NFORMATION: a o s$ 5h �1�G l�n e �f�� Job Site Address: Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes ❑ No /f yes,a speaal evooni permlt is repuiied wl�Pdke Depertment and Ciry Coun�ll approvel 80 days prlor fo�e evenl. ShuGde bus ssrvice will be required unless applicanf demonstrates sufticlent on-sita parkinp is aveifable. Non permlCed e�nents will not be anowed. CONTRACTOR/APPLICANT INFORMATION: , Name: THD At-Home Services, Inc. �o d i State�icense# 2690 Cumberland Pkwy, Ste 300 a 3Y�7 Phone: (cell) n�ai�ing Address: Cumberlaz�td Office Park ZIP: Contact Person_ � Atla�nta, GA 30339-3913 lomeovm�r cca��a cna) Emai�and/or�ax:- Lic#29268257 Ph. 763/542-8826 c!t p'ROPERN OWNER�FORMA7IQN; Name: Q� Q �E l`f . Phone(day): q s? 3 � Y S�3 9/ Address: o � ti /, � c� : 0�o n o z�P: Emaii and/or Fax � , PROJECT INFORMATION: Type of Project:: My earth movement may require I . MCWD review�permtts ❑ Door(s) ❑Remodel ❑water Damage Minnehaha Cresk Watershed DI&trict(MCWD) ndowts) '�iepair ❑Storm Damage 18202 Mfnnetonka Blvd Deephaven, MN 55391 ❑Siding ❑ Restoration ❑Other(speclfy) phone: 952-�71-0590 Fax: 952-471-0682 ❑R�roaf ❑Fire Damage www.minnehahacreek_oro Overall ProJect Descriptien: W� •s f t/1 //) � P/� i 0 S Estimated Constructivn Valuation of PreJect(excl ding land) $ ,� �' APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; . Certfies that tJ'�e information supplled is true and co11'ect to the best of his/her knowledge. The applicent 1'eoogn¢es that they are solely responsible for submitting a complete applicaUOn being awsre that upon failure to do so, the staff has no attemative but fo reject it until it is complete; • Some or all of the informa'tion that you are asked to provide on thls appficatlon is classi�ed by State law as either private or coMiderrtial. Private data is ir�formation which genereily cannot be given to the public but can be given to the subjed of the . I data. Confider�tial data is information which generally cannot be glven to either the public or the subJeG of the data. Our purpose and intended use of this Infomnation is to snnually update our records and reeords of other governmental agencies re uired b law. If ou refuse to su I the information,the a lication ma not be issued. ApplicanYs Signature: x �� Date: �l �O L r 3 . l ` �....a I I...I..inA• 11PJ1A_7M0 �