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JUN/25/20112/MON 10:30 PM FAX No. 952 854 4909 P, 002 City of Orono Building Permit Application for Internal Work windows, doors, siding, re-roof, etc.) w.f) Mailing Address: Permit number: Q PO Box 66 Crystal Bay, MN 55323-0066 Date received: StreetAddress: Received by: 04 2750 Kelley Parkway Plan review fes: og� Orono,MN 56366 1 -5 Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.,rZs A Total Fee: 7.39 This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please tint) GENERAL INFORMATION' ! /`� LJ� �0 Job Site Address: 3 0 S Q 7 Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes ❑ No m yes-a vocial event permit is requited w/M Polios Department and City Council approval 60 days prior to the event shutue bus service will be required unless applicant dernonstmtes sufficient on-site parking is available. Non-permhted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: THD At-Home Services, Inc. State License# 2690 Cumberland Pkwy, Ste 300 Phone: (cell) Mailing Address: Cumberland Office Park ZIP, Contact Person: Atlanta, GA 30339-3913 lomeown r (circle one) Email and/or Fax: )(,X#20268257 Pia. 763/ 542-8826 q.213 V S 401/7 J0 d, PROPERTY OWNER INFORMATIQN: /a Name: fj Phone(day): QST J Address: SII o 11` Ci : l o A 1 4 4 ZIP: S 5*3 S6 Email and/or Fax e• PROJECT INFORMATION: y can earth movement may require Type of Project: MCWD review&permits ❑ Door(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) ❑Window(s) %-QRepair ❑Storm Damage 16202 Minnetonka Blvd Deephaven, MN 55391 ❑Siding ❑Restoration ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 Re-roof ❑Fire Damage www.minnehahacreek.oro Overall Protect Description: Estimated Construction Valuation of Project(excluding land) $ .9 APPLICANT ACKNOWLEDGEMENT: Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information.which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies required by law. If you refuse to supply the information,the application may not be issued. Applicant's Signature: Date: Gf� Lltl �