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.�,PP, '16, 201�%':'�'.0 'J�; ��; ��.".�'. FAn No, 95� �54 ^G�° P, 002
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<br /> � City of Orono 4 z! °
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<br /> Building Perrni� Application for Internal Wark
<br /> (wirtdows, doors, siding, re�roof, etc.)
<br /> M�iling Add�ass: ✓ c
<br /> `g,0�. PO Box 66 P�rmit num6er. ��.y '" �'�
<br /> �Q � a Crystal Bay,MN 55323-0066 Date received: b �� ( �
<br /> �"°"�0` Received b
<br /> 3 ,i�lr�r�.,? ,,,, 5treetAddress: Y�
<br /> 'io-r'AI4 ".- .
<br /> '�, ;rl�,��»�':g ti 2750 Kelley Parkway Pfan review fee_ -�
<br /> L_`��°'"�'~+;����G Orono, MN 55356 �
<br /> '�t�s� �
<br /> Total Fe
<br /> Main: 952-249-d6p0 Fax: 952-249-46�16 www,ci.orono.mn.us � .(,L.�O ^. '�
<br /> This application Torm must be completed in full and all required informatidn must b submitt d. � I,I,,� `j�`����1
<br /> Incomplete applications will be returned. (Please print) ����U�'/ �� �g',� ,,pS�
<br /> GENERAL INFORMATION: .��,�,� I Ya�`N'
<br /> ,�ab site,4ddress: � L 3 b � l�, .� � �'S.L '
<br /> Will this be a Parade of Homes, Rerriodel�rs Showcase Hame or other Dispfay Home? Yes No
<br /> If yes,a spacia�aver,t permif is re�ui�ed wlth Pol/ce Department and Clry Council approva!6o days pr;or(v th�evenf. Shuttle bus servlce w!!1 be
<br /> requirsd unless applicant demonstratss sufflclent onslta park;ng is availa6le. Non-permitted events wilf not be allowed,
<br /> CONTRAGTOR/APPLICANT IWFORMATION:
<br /> Name: ...__ qS� '��6'• �0'Y7
<br /> 5tate �icense.# � THD At-Home Service, �nc, .ja vy
<br /> Ph�ne: 2690 Cumbez'land Pkwy, Ste 300 (cef�
<br /> Mailing Address: 1�tlazzta, GA 30339-3913 ZIP� �
<br /> Contact Perso�: ._ Y,ic#C�,268257 Ph. 763/542-$$2( �omsowner (Clrcle One)
<br /> Emaii and/or Fax�
<br /> PfZOPERTY QWN�ft IN��R TION:
<br /> Name: Q ��r c.h � o n
<br /> Phone(day)� L� �b $ � O m
<br /> Address= 3V�„� , ,l1,.� ,4 � Git :r'(@ � ��asA ZIP� 'SS� 'S' �
<br /> Email and/or Fax
<br /> PROJECT INFORMATIQN: �
<br /> Type of Project: Any earth mpvement Rlay require
<br /> " MCWD review& permits
<br /> ❑ �oor(s) ❑ Remode� ❑water�amage
<br /> Minnehaha Creek Watershed DiStrlCt(MCWD)
<br /> �]Window(s) �j Repair ❑Storm Damage 18202 Minnetonka Blvd
<br /> • Deephaven, MN 55391
<br /> ❑Siding [] Restoration �Other:(specify) . Phone: 952-471-0590
<br /> ❑ Re-roof f��'"!L l/� 5, Ft�x: 952-471-0682
<br /> ❑ Fire Dam�ge w�nn�v.mi�n h qrC�
<br /> Overall ProJect Descript�pn: � � D -''� / j�, /p ! C l
<br /> Estlmated Construction Valuation of Project (excluding land) $ � Q Q �
<br /> APPLICANT ACKNOWLEDGEM�NT:
<br /> • AUrees to provide all information required or requested by the Building Department;
<br /> . Certifies that the information Supplied is true and correct to the b�st of his/her knowledge. The �pplicant recognizes that they
<br /> . are solely responsible for submi�ting a complete application being aware that upon faflure t0 tlo 50, the staff has no alternative
<br /> ' but t0 fejeCC it until it is complete;
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<br /> • Some or all of the fnfOPma[ion th�t you are asked to provide on thls appliCation is cl2ssified by State law as either private �r
<br /> Confidenti�l. Private data is information which generalfy cannot be given to the public but can be given to the subject of the
<br /> data. Confidential data IS inform�tion which generally cannot be given to efther the public or fhe subject of the data. Our
<br /> purpose anc] intended use of this in{ormation is to annually update oUr records and records of other governmental agencieS
<br /> required by law. If you refuse to supply the infprmation,th a IlCation ma not be issued. `
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<br /> Applicant's Signatuie: Date: �
<br /> Las!Uptlated: 05-04-2009
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