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APR/09/2015/THU 03: 06 AM FAX No, 952 854 4909 P, 002 <br /> � City af Orono <br /> Bui[ding I�ermit Application for lnterna� War�C <br /> {windows, doors, siding, re-roof, etc.) <br /> Mailing Address: P�rmit number. � l S J�� � <br /> /�/ d,�. PO Box 66 <br /> /O �� a Crystal Bay, MN 55323-0066 Date received: _�/� •-C � <br /> II ��� � Received by: � <br /> ,� �;�_��';^�,:�� a Stre6t AddrQss: <br /> ��,����'��� �4`' 275D Kelley Parkway Plan review fee: <br /> �e��s�o�;,�v Orono, MN 55356 . <br /> �= 7otal Fee: ,��,�� , Cj f � ( <br /> Main: 952 249 4600 Fax: 952-249-461 o www.ci.orono.mn.us � <br /> � This application form must be corn�leted in ful{and aEl required information must be submitted. � <br /> �ncomplete applications will be returned. (Please print) <br /> GENERAL INFORMA71dN: / 1 <br /> Job Site Address: � y�7'J� L ! V t/� Q �T C�/� V�� �/� <br /> Will this be a Parade of Homes, Remodefers Showcas Home or ofher Display Hame? ❑Yes ❑ No <br /> lfyes,a speclal event perm/t!s required with Po�fce Departmeni and Cl��Councll approv�l 60 c�r�ys prior to the event. ShutEle bus service wlll ba <br /> requlred unless applicant demonstrates sufficienf on�siCa parking!s ava!!ahl�. Non-permitted evenls wi��not be ai�owed. <br /> CONTRACTOFt/APPLICANT INFORMATION; 4���,� <br /> Name: Tv1e. {—l�ri� c""Ff"� �` -._ Q'�2 3YS•L 0 y <br /> State License# ��^ � 'T' At-Home Service, Inc, o �� <br /> Phone� ___ 269p Cumberland Pl�wy, Ste 300 "„ (cell) <br /> Mailing Address: Atlanta, GA 30339-3913 Z�p <br /> Cantact Aerson� LiC#CR268257 Fk�.. 763/542-8826 ►omeowner (Circle One) <br /> Email and/or Fax: <br /> PfiOPERTY OWNER INF�RMATION: <br /> Name: ,�I'I C�Q !. � �Q ! C�j"��G d <br /> Phone (daY): �Z 0 � � I���7 . [,�3Q 'Z (y'�(�l ZIP: 'rJ'S� <br /> Address: ti Y C �� � 3 �/ <br /> Email and/or Fax <br /> PROJECT INFORMATION: - A <br /> Type of Project: - Any earth rnovement may require <br /> ' MGWD review&permits <br /> ❑ Door(s) ❑ Remodel ❑W.ater Damag2 <br /> Minnehaha Creek Watershed�Isirlct(MCW�) <br /> indow(s) ❑ Repair ❑Storm Damaga 18202 Minnetonka Blvd <br /> , D6ephaven,MN 55391 <br /> ❑Siding ❑ ReStOC&ti0fi ❑Other:(specify) . Phone: 952-471-0590 <br /> Fax: 952-473-0682 <br /> d Re-roof ❑ Fire Damage www,minnehahacreQK,�4 <br /> Overafl Project Description: i} !j 1 �!! / <br /> ^ �stimated Construc#ion Valuatidn of Project(excl ing land) $ � � Q � <br /> , <br /> l�PPL1CANT ACKNOWLEDG�MEN7: <br /> • Agregs to providE afl information required or requested by the Building Department; <br /> � Certif,es that Yhe information supp€ied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> , ' are soiely responsible for subrrlitting a complete application being aware that upon failur�to do so, the staff has no altemative <br /> but to reject it until it is complete; <br /> • Sorne or au of the information that you are asked to provide on this ap�lication ls classlfled by State law as either private or <br /> confidential. Private data is information which generalfy cannot be given to the public but can be given to the subject of the <br /> data. Gonfidential data is informa�ion whlCh generally Cannot be given to either the public or ths subject of the data. Our <br /> purpose and intended use of tnis information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I the information,the a lication ma nof be issued. <br /> ApplicanYs 5ignature: ���� Date: [ 1� C l S <br /> �a�t Updated: 05-04-20Q9 <br />