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1UN/27/2013/THU ?0. 3? ?� Elder Jones Building FAX No, 957 ��54 490� P, 002 <br /> � <br /> ' City o�' Urono <br /> Building Permit Application fo�- Internal Wo k <br /> (windows, doors, siding, reWroof, etc.) <br /> IvlailingAddress: Permitnumber: i �f"� �j <br /> /O y_O�O 1 Crys�tal B�y,M N 55323-0066 I Date recaived' –�s� <br /> '�T,�, I <br /> .C� � Recaived b ' � <br /> .� F�,'✓3��:Y� a.� StrEetAddress: y ' <br /> '� ;���,��,��r�ll,� �ti`� 2750 F<elfey Parkway Plar,review;ee: i <br /> � �-a : <br /> l���s�o� brono, MN 55356 � <br /> �1 7otal �ee: ��p�a� �� <br /> Main: 952-249-4600 Fax: 952-249-4616 v�nnrw.ci.orono.mn.us <br /> This applicatian form must be complete�d in full and all required information must be sut�mitted_ <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMA71dN:�00 �a ,� lo n ��('Q /) j,�.Q, ' <br /> Job Site Address: <br /> Wil!this be a Parade of Homes, Remodelers Showcase Home or other Display Home? � Yes No <br /> /f yes,a specia/event permit is required with Police Depanment and Gify Gouncil approvaf 60 days pr;or Po the evanL Shu�t/e bus service w1ll ba <br /> required unless appllcant demonstratas sufficienP onsite parking is a�arlab/e, Non-permittetl events will not b allowed. <br /> CONTRACTOR/APPLICANT INFORMATIpN� <br /> Nam�= Jed� • qS� ��5- G a vy <br /> state�icense# THD At-�Iome Service, Tnc, <br /> Phone� _ 2690 Cu�mberland Pkw�r, Ste 300 cell) <br /> Mailing Address= At�anta, GA, �0339-3913 I�IP: <br /> Contact Person: Lic#CR268257 I'�. 763/542-5826 lomeowner �c.��e o��> <br /> Email and/or Fax� <br /> PROPERTY OWNER INFO�ATtQN: /1 �i <br /> ��ame: Q 6t � f� e n � � �-�� , <br /> Pnone(day): � b n � � 3 <br /> Address: 5 D 0 Q n u n t�x t ,� c� :GJ'u Z a�c �iP. S 5,� 9/ <br /> Emai!and/or Fax <br /> PROJ�CY INFORMATION: � <br /> � Type of ProJect: Any earth movemer�t may require <br /> 1UICWD review�permits <br /> � ❑ Door(s) ❑ Remodef ❑ Water Damage <br /> � Minnehaha Creek Watershed District(MCWD) <br /> ,��/indow(s) ❑ Repair ❑ Storm Damage ! 18202 Minneto ka Blvd <br /> Deephaven,Mt�! 55391 <br /> ❑Siding � � Restoration ❑Other.(specify} Phone: 952-47,1-0590 <br /> Fax: 952-47'Q-0682 <br /> ❑ Re-roof ❑ �ire Damage www,minnehaha reek.or <br /> Overall Project Description: (r (,,,i i!� U c! �� �'Cl. !� � � 0 !� /�t'/ <br /> Estimated Construction Valuation of Project(excluding land) $ 4l j 5'�? � <br /> . II <br /> APPLICANT ACKNOWLEDGEM ENT: <br /> • Agrees to provide all information required or requested by the Bui(ding Department: <br /> - Certifies that the infarmation s��pplied is true and correct to the besi of his/her knowledge. The appliC nt recognizes that they <br /> are solely responsible fpr submitting a complete applicetion being aware that upon failure to do so, the�staff has no al#ernative <br /> ,� <br /> but to reject if unti!it is complete; <br /> � • Some or all of the information that you are asked to provide on this application is classifi�d hy State aw as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be giv�n to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the su�jeet of the data_ Our <br /> I purpose and iniendsd use of this information is to annu2lEq upd2te oU� reCOrds and r�cords of other overnmental ayencies <br /> � required by law. If you refuse to supply the information,the applicatiqn ma nOt be issued. � <br /> — <br /> �''� c. ,� g(� 3 <br /> ApplicanYs Signature� �6� Date: <br /> � <br /> i <br /> Last Updated� OS-04-2409 <br />