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City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> �� I►� PO Box 66 <br /> �`V Crystal Bay, MN 55323-0066 Date received: <br /> °��t;.:��. ° <br /> Street Address: Received by: <br /> ,� � �J��.T:� s. <br /> `� ,; z%�"p � 2750 Kelley Parkway Plan review fee: <br /> �'LykESH�g,�'vG Orono, MN 55356 <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: �/� .> <br /> Job Site Address: ��a'� � �� � �� ��- e� <br /> Will 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 Po/ice Department and City Counci/approva/60 days prior to the event. Shutt/e bus service wi//6e <br /> required un/ess applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: _ � THD At- Home Services, Inc. Jod, co F`T P,tr��� <br /> State �icense# 2690 Cumberland Pkwy, Ste 300 �S� 3'/S • 4 o V 7 <br /> Phone: (cell) <br /> Mailing Address: Cumberland Office Park ZIP: <br /> Contact Person: Atlanta, GA 30339-3913 iomeowner (Ci�cle One) <br /> Email and/or Fax: Lic#20268257 Ph. 763/ 542-8826 <br /> PROPERTY OWNER�I FORMATION:_p n� � <br /> Name: /'!q I`[d (�1 <br /> Phone(day): 9 5 a y?4 • 4 G O G p L <br /> Address: /S�'S [0/16 �lr b�L�� Ciry: �!`DnO ZIP: 'sS3 's <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 /> �(IVindow(s) �tepair ❑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.orq <br /> Overall Project Description• W i�l n W ��� Q u�!� �/) ,/�'/ t ! � � bQl��n�'S <br /> Estimated Construction Valuation of Project(excluding land) $ 5 $ $ V <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 /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: � Date: � l � `3[ � � <br /> � <br /> Last Updated: 05-04-2009 <br />