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+ S <br /> � City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> �:�L,� J1� PO Box 66 <br /> �' �V Crystal Bay, MN 55323-0066 Date received: <br /> ;� � d`;`, <br /> I; '`;� � � Received by: <br /> i�a j, r�; s.�� Street Address: <br /> \�`�,E, �'��^ ����. �� �ti!�' 2750 Kelley Parkway Plan review fee: <br /> �,l ��' ��'�r' ��tv,;��� Orono, MN 55356 <br /> ��kESH�� '� <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: L <br /> Job Site Address: � q l� �O �! s `_ �� S d n Q• <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: /tl d� QS' /3 y� 'L 0 y 7 <br /> Name: �� � <br /> state �icense# THD At- Home Service, Inc, <br /> Phone: 2690 Cumberland Pkwy, Ste 300 (cell) <br /> Mailing Address: Atlanta, GA 30339-3913 ZIP: <br /> Contact Person: Lic# CR268257 Ph. 763/542-8826 lomeowner (Ci�cle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER IN 0�2MATIOfI: <br /> Name: /1 a r !.� a � <br /> Phone (day): 6 a � Y�f • 7� L / �y�1 <br /> Address: 0 I /'!�1 S G. /� Cit : , -` 0 V n � ZIP: 5sc3 G <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> Window(s) epair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.or <br /> Overall Project Description: (,� f,.i � /1 �W /'� Q � /h 0-n S //� L / ) n O �^ 1l� <br /> Estimated Construction Valuation of Project (excludi g land) $ oZ 9 / (i l� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies 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 complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> required b law. If ou refuse to sup I the information,the application ma not be issued. <br /> ApplicanYs Signature: <br /> � Date: � � 7 �/ ( <br /> Last Updated: 05-04-2009 <br />