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MAF��4/2013/SUN 11 : 44 PM FAX No. 952 854 4909 P. 002 <br /> , <br /> Cifiy of �rono <br /> Buiiding Permifi Application for (nternal Wor�C <br /> (windows, doors, siding, re-roof, efic.) <br /> MailingAddress: Permit number: �������"I <br /> Q^�t,�,�� PO Box 66 <br /> CrysCal gay,MN 55323-�066 Date received' <br /> '��;;-�-:. <br /> �ryy �`��'}�' F,y' Street Address: Received by: <br /> µt f�r�yV!��d`'14�'. CY <br /> � �"o oti 2750 Kelley Parkway Plan review fee: <br /> ��Bxf�sK�O� Orono, MN 55356 <br /> Total Fee: , /J�g� �� <br /> M�in: 952-249-4600 Fax: 952-249�4616 www.ci.orono.mrl.uS '" � <br /> Yhis application form must be completed in fuEl and all required information must be submitted. <br /> Incomplete applications w111 be returned. (Please printJ <br /> GENERAL INFORMATIpN:� „� � y�Q k� � <br /> Job Site Address: �Q/`� Q�Q ,� �5 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other bisplay Home? Yes No <br /> !f yas,a specia!event permit is requirad wfth Pollce Department and Clty Council approva!60 days prior to tha event. Shutele bus servic�will be <br /> �equired unless applicant demonstrates su�ficient on-site parking is avar/able. Non-permitled events will not be al/owed. <br /> CONTRqCTOR 1 APPLICqIVT IN�bRMATlO[�f: <br /> Name: �ts�. � ����l' �a61�s <br /> State License# THD At-I�ome Servic�, �c, Q S.? 3 • a Y 7 <br /> Phone� 2690 Cumbe�rland P�Cwy, Ste 300 (ceA) <br /> Mailing Address� ,Atlantl, CrA 303�9-3913 ��P� <br /> Cont�ct Person: Lac#�CR268257 p12. 763/542-$$26 �omeowner tc�ra one� <br /> Email and/or Fax: <br /> PROPERTY OWNER INF RMA 1 N: <br /> Narr�e: Q a ! d /Z <br /> Phone(day): G !� Z ( • q / <br /> Address: y p Ci = �.1G ��7'Q ZEP: ��� 4 <br /> Emaif�nd/or Fax <br /> PROJECT INFORIVIATION: <br /> Type of Project: Alty earth movement may require <br /> (� Door(s) ❑ RemodEl MCWD review&permfts <br /> ❑Water Damage <br /> Minnehaha Creek Watersh�d District(MCWD) <br /> �WifltlOw(s) �epair �Storm Damage rt$202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> ❑ Siding �Restoration ❑pther:(specify) Phone: 952�71-0590 <br /> � Fax; 952�471-0682 <br /> ❑f�e-roof ❑ Fire Damage www.m nehah2cr ek.or <br /> Overall Project Dascription: / („�� o t.,� F 1/� � � '� � '�9 <br /> �stimated Construction Valuation of Project(excludin land) $ / 5.1 b <br /> APPLICANT ACKNOWLEDGElIfIENT: <br /> • Agrees to provide al!information required or requested by the Building Department; <br /> • CGrtifies that the information supplied is trUe and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a cornplete appliCation being aware that upon failure to do so, ihe staff has no alternative <br /> but to reject it until it is compfete; <br /> • Some or all of the infol'mation that you are asked to provide on this application is classifred by State faw as either private or <br /> confidential. Private data is irrformation which generalfy cannot be given to the public but can be given to the sUbj6Ct of'Che <br /> data. Cpnfdential (iata is infprmation.WhiCh generally cannot be given tp either Ihe public or the subject vf the data �ur <br /> purpose and intend�d use of this information is to annually update our records and recorps of otiher governmental agencies <br /> re uired b law. If ou refuse to suppf the information tha a lication ma not 4e issued. <br /> �- � ��� � � s��� <br /> Applicant's Signature� C� Date: <br /> Last Updated: 05-04-2009 <br />