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��T'�'� �.� �Ri D4 �'� Al'� Elder Jones Building �n� �i� ��r� 8'�4 79�i � G:. ♦ r City of Orono Building Permit Application for Mainfienance / Replace�nen# 1 Remodei �i,�� rrindaws, doors, sidin�, reWrca�f, �tc, — N� STRtJCTt1R�oL �XP,4NSI�N} MarlingAddress: P�rmit number.- L'�'f `�-- �' I c: � �� �� PO Box 66 I Crystal Bay, MN 55323-0066 , Date received: � � :�� I_� E � � StreetAddress: � Received by: C� 2 y� G� 275�Kelley Parkway Plan review fee: /� �XFs�[o�� Orano; MN 55356 Total Fee� �]�-� �I �-- Maln� 952-249-4600 Fax: 952-249-4616 www_ci.orono.mn.us F This appiication form must be completed in full and all required information must be submitted, h�complete applications will be returned. (Please print) GEHERAL INFORMATION: o Job Site Address. � � � t �G �` V l C W � � � Will this be a Parade of Hon�es, Remodelers Showcase Ncme or other Display Hame? ❑ Yes ❑ Mo !f yes,a Specfa!event permit is r�quired v✓ith Polrce Department and City Cocrncil app�`oVa!60 days prior to fhe evenE. Shuttle bus service Will be required unless applicant demonstrates Sufflclsrrt onslte parking Is avallabla. Non-permiited events wfl!not be allowed_ CQNTRACT012/APPLICANT INFORMATION: Name: T��7 At-Hoine Service, Inc, gS?�3�l S ' �b 4 � .l a Cl� State �icense#� 2690 Cu�xiberland Pkwy, Ste 3Q0 �xpiration Date: Lead Certification Number_ . Atlanta, GA 30339-3913 � Expiration Date: (torwork on homes thatwe+ �ac#CR26$257 Ph. 763/542-8826 Phone: (cell) �e) Mailing Address: City: �Ip� Cont�Ct Person: Applicant is= Gontracto / H�meowne�- (circ�e one) Email and/ar Fax� Pi20PERTY OWNE INFORMATIQN� Name: � ( f� Phone (day): � 5 a • � 5 3 Address: 3 0 S R o P Y t c r,��4 n C c�ty: �P o � o ziP: S 5 3 x � Email�nd/or Fax: PRO�JECT INFORMATION: Overall praject description: C l`r�/b C'�o �l' /'e !d /'? 4 n /" ! Type of Project: Any earth movement may also raqulre I MCWD revlew S�permlts: ��Door(s) l-PG �J o � Remodel ❑ Fire DamaQe ❑Re-roof,asphalt �tepair ❑Storm Damage Minnehaha Creek Watershed District(MCWQ) 18202 Minnetonka Blvd � Re-roof,cedar ❑ Restorat;on ❑Water Damage Dsephaven,MN 55399 ❑ Re-roof,other(specify) ❑ Siding ❑Other: (specity) Phone: 952�71-0590 Fax: 952�71-0682 I V ❑Window(s) www.minnehahacreek.crc� Estimated Construction Valu�tion of ProjecE(excludtng land) $ �J APPLICANT ACKNOWI��I7GEMENT: • Agrees to�rovide all information required or requested by the 6uildiny Pepartment; I • Certifies that the information supplied is true and correct to the best of his/her knowledge. 7he applicant recngnizes that thay ara I SoE91y responsibl�fpr submitting a complete appfication being aware that upon failure to do so, the Staff has no alternative but to rejBCt it until it is complete; I . Some or all of the Information that you 2re asked to provide on this application is classtfied by State law as eifher private or confdential. Private data is informaflon whlch generally cannot be glven to tt�e public but cari be given to the subject of the data. Confldential data is information which generally cannot be given to eifher the public or the subject of the data. Our purpose and fntended use of this information is to annually upd�te our recards and records of othe;r governmental agencies required by taw. If oU refUse to Su I the infnrmation,the ap licafion ma not be issued. Applicant's Signature: Date� � � � � Owne�s Signature: Date� Last Updated:January 2015