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JU�'!?G%'2uiG/NIvN 03; 33 PM Elder Jones Building �Al "io, 952 854 4909 P, CO? <br /> � . <br /> C�ty of O�ror�o <br /> Building Permit Application for Maintenance / Replacem�nt ! Remodel - Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc, - NQ STRUCTURAL EXPANSEON) <br /> �Q A TO Ma�ling Addross: � � , >� <br /> Permif number: �-� C-= t', ;, <br /> 1 V P�Box 66 <br /> Crystal Bay, MN 55323-0066 Dafe recelved: � �vZU/(v <br /> � � <br /> Sfreef Address: fteceived by: <br /> ti G�� 2750 Kelley Parkway Plan review fee: <br /> `� Oronci, MN 5�3�6 <br /> t4'�ES Fl�4`� <br /> Total Fee� �`�� / �-�, %: ,; <br /> Main: 952-2A9,4600 F'ax: 952-249-�}616 www,ci.orono.mn.us �-- <br /> This applicatiort form must be completed 'n�full and all required information must be SUbmitted. <br /> Incomplete applicatEons wlll be returned. (Please prinf) <br /> GEN�.RAL INFORMATION: a 7 ,� � �^/ �j <br /> Job Site Address: G 7'h !. ,j T'7'V C � U <br /> . <br /> Wf11 thls b�a Parade of Homes, Remodefers Showcase Home or other Display Home? Yes No <br /> If yes,a sp¢cia!evanf permit is r�quirsd wlth Pollce Depanrnenf and Clfy Cound!approva/60 days prror to the evenL Shuttfe bus sorvlce wll/be <br /> requliBd unless applrcant demonstrates suf�icient on�sitQ parking is avalla,Gle. Non-permltted evenfs wll!not be allowed. <br /> CONTRACTOR/APPLICANT 1NFORMATION: <br /> �Name: THD At-Home Servace, Inc, <br /> state �icense# 2G90 Cu�nbe�Iand Pkwy, Ste 300 e� <br /> Lead Certification Number: Jv�T, / q� �y •� ,p,,t�az�ta, GA 30339-3913 e= � <br /> (for wa•k on homes that wero constructed�rlol'fo �,zc#C�Z268257 Ph. 7�i3/542-8826 <br /> Phone: (cell) <br /> Mailing Address� Cit � ZIP: <br /> CotltaCt Person: Applicant is: Contractor Homeowner (Clrcle dne) <br /> Email and/or Fax' p C1 I s m � 1 d �r �a ��.., �a l� �,_ <br /> PE�OP�RTY QWN�R I FORMATION: <br /> Name: � Q /'l$ Lj <br /> Phone{day)� Q S� �o Y 9 • 7 0� <br /> �ddress: 2 7 � D Er-�fi R�v�e _ c��y: (,�a Y z a t�a ZIP: 7'� 3 �� <br /> Email and/or�'ax: <br /> PROJECT INFORMATION: Overall prnject description: <br /> Typo of project: � pny eartl�movement may also requ(re <br /> ❑Door(s) �f Remodel ❑ Fire L7amage NICWD review&permlts: <br /> ❑Re-roof,asphalt ❑ Repair ❑Storm Damaqe Mfniiehaha Creek Watershed District(MCWp) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetanka,MN 55345 <br /> ❑ Re-roof,other(specify) ❑Siding ❑Qthar:{specify} Phone: 952-471-05s0 <br /> .�C, Fax: 952-471-0682 <br /> �I Window(S) www.minnehahacreekLQrg <br /> � - <br /> Estimated Construction Valuation of f�roject(excluding land) $ <br /> APPLICANT ACKNOWLEDGENEENT: <br /> . Agrees to provide a11 information required or requestetl by the Building Department; <br /> • Certifies that the Enformation supplfed is true and corract to ihe best of his/her knowledc�e. The applicant recognizes that they are <br /> solely responsible for submitting a complete applicatian being aware that upon faflure to do so, the staff has na alternative but to <br /> reJect It until it is camplete; <br /> • Same or all of the information that you are asked to provlde on this app)i�ation is classified by State law as either prlvate or <br /> confidontial. Private data is information wl�ich generally cannot be given to the public but can be given to the subJect of the data. <br /> Canfidential data is information wliich generafly cannot be given to eifher the public or th�subject of the data. Our purpose and <br /> int�nded use of this information is to annually update our records and records of othor governmental a�encies required by law. If <br /> ou refuse fo su I the information, t e�llcation ma not ba issu�d. <br /> Ap�licant's Signature_ � Date: �" °�� � �' <br /> Owner's Signature' Date� <br /> Last Updatsd�January 2�16 <br />