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MAY/24/2011/TUE 11 : 33 PM FAX No, 952 854 4909 P 002 <br /> � <br /> t <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, sid'[ng, re-roof, etic�) <br /> ��-� MailingAddress_ Permit number: o�� /l- UO�9'/ <br /> ,�Q� PO Box 66 . <br /> Crystal Bay, MN 55323-0066 Date reCeived: / � <br /> O'�^�,�,. � Received by: ^ �-� <br /> �'�•�7� a, Street Address: <br /> ,� � ����;.,,, �. <br /> S� 4� �� a��� � 2750 Kelley Parkway Plan review f9e: <br /> t�'� ��y�$° OrOno, MN 55356 / � 'i <br /> k�s��� Total �ee: � �4-''�, �� ..,�r���� <br /> Fax: 952-249-4616 www.ci.orono.mn.� ; `��� G? <br /> Main: 952-249-4600 - <br /> This application fo�m rr�ust be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> G�NERAL INFORMATfON: � � g �0/` O/) CI c� � /ri O CI Q� <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> !f yes,a spec/a/event permit Is required wlth Police DepaRment and Ciry Council epprova/60 days prior fo the event. Shutt�e bus seivlce will be <br /> required unless appllcant demonstrates sufficienr on•site parking is availabla. Non-permitted avenrs will not be allowBd. <br /> CONTRAGTOR/APPLICANT INFORMATION: J e �� �, �rd�r JD n� 5 <br /> Name: THD At- �-Iome Services, Yt�c. <br /> S�ate License# 2690 Cumbezland Pkwy, Ste 300 95� 3yS • G e y � <br /> Phone: ������— <br /> Mailing Address: Cu�nberland Office Pazk ZIP: <br /> Contact Person: Atlanta, CrA 30339-�91� lomeowner �c�«iao�e) <br /> Email andlor Fax: �,xc#202682�7 Pli. 763/ 542-8826 <br /> pRaPERTY OWNER INFORMATION: �t� � � <br /> Name: J��� �C <br /> Phone(day): `�a? [. ' `t�5/ <br /> Address: �S Sk o /l D/� c�/� �� !�� c�ry: fJ(�!/Z G�� zip: S S 3 9 / <br /> Email and/or Fax <br /> PROJ�CT IN�ORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD revlew&permits <br /> �Door(s) /-P d ❑ Remodel ❑water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> �Window(s) f� �Repair ❑Storm Damage 18202 Minnetonka Bl�d <br /> Deephaven, MN 55391 <br /> �Siding ❑ Restoration ❑ Other. (speCify) I'hone: 952�471-0590 <br /> Fax: 952-471-0682 <br /> e-roof ❑ Fire Damage WWw.minnehahacreek.of4 <br /> erall Project Descriptlon: � -!'0 o e�,t r �� W,n�✓V g.�S � / 4 i o (!��o/ � �fi!�'�I/)7� <br /> Estimated Construction Valuation of Project(excluding (and) $ q 8 G J <br /> APPUCANT ACKNOWLEDGEMENT: <br /> . Agrees to provide all information required or requested by the Building Department: <br /> • Certifies thai the information supplied is true and correct to the best of his/her knowledge. The appfic2nt recognizes that they <br /> are solely responsible for submitting a Complete application being aware that upon failure to do s0, the staff has no altefnative <br /> but to rejact it until it is comp(ete; <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 /> confcdential. Private data is irrformation which generally cannot be glven to the public but can be given to the subject of the <br /> data. Confldential data is informatlon which generally cannot be given to either the public or the subject of Lhe data. Our <br /> purpose and intended use of this information is to annually update our records 8nd records of other governmental agencies <br /> re uired b law. lf ou refuse to su I the information,the a IiCation ma not be issued. <br /> Applicant's Signature: <br /> �'�6� Date: 'J �� S l!� <br /> �v�.��„�aTA,,- n�_na-�no. <br />