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JAN/19/2015/MON 03: 33 AM Elder Jones Building FAX No, 952 854 4909 P. 002 <br /> � � ' � <br /> � ' City of �rono <br /> Building Permifi Application for Infiernal Work <br /> (windows, doors, siding, re�roof, efic.) <br /> �.-^� MailiRgAddreSs: Permitnumber: Q�l�'(�/v� <br /> �g,o.�.O Po Box as <br /> Crysial Bay,MN 55323-0066 Date receiv�; - .20 /J <br /> v�_. <br /> �\� ,'`�'. �_ a� Street Address: Recen+ed by: <br /> .� � �ti�' 2750 Keflay Parkway Plan reviewfee: <br /> ��o�s.� Qrono, MN 55356 � � <br /> — `rota� Fee: ,,p�, 3 <br /> Ma�n; 952-249-4600 �ax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be cvmpleted in full and all required information must be submitted. <br /> Inc�mpleta applications will be returned_ (Please prinfJ <br /> GENERAL 1NF�RMATION: � � � � F� � ��� <br /> Job Site Address: <br /> Will this be a Parade of Hpmes, RemodeEers Showcase Horne or other Display orne? Yes �] No <br /> !f yes,a speclal event p�rmrt is required with Po/ice Departmant and City Counci!approva!60 days prlor to the event. Shuttle bus servlce wrll be <br /> requl�ed un/ess applicant demvnstrates sufticlent on-srte parlcing is avai/abJe. Non-permltted evenls will not be a!lowed. <br /> G�NTFZACTOR!APPLICANT Ii�[FQRMA710N: <br /> Name: QS� 3 Y • G b�I � <br /> State License# THD At-Hozue Service,Tnc, � <br /> t�hone: 2690 Cunaberland Pkw�r, Ste 300 (ce1,� <br /> Mailing Address� Atlanta, GA 30339-39X3 Zlp= <br /> Contact Person: Y,ic#CR26825'7 ph. 763/542-8826 {Q'71�owner �ci«�o�> <br /> �mail and/or Fax: <br /> PRQP�R7Y OWNER INFORMAT�ON: <br /> Name: �,�1 �M � <br /> Phone(day): Q � � 7 . D I, � <br /> Address: y City� d 1'p I)� ZIP: $S 3 Q ! <br /> Email and/or Fax <br /> , PROJECT INFQFtMAT10N: <br /> Type of Project: A1�y earth movement may require <br /> ❑Door(s) ❑Remodel MCWD revlew&.pennits . <br /> ❑Water Damage <br /> • Minnehaha Creek Watershed District(MCWD) <br /> �1Nindow(s) `�] Repair ❑Stbrm Damage 18202 MinnetOnka BIVd <br /> /� <br /> r ' Deephaven.MN 55391 <br /> ❑Siding _ ❑ResYoration ❑Other.(specify) , Phone: 952-1171-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑Fire Damage � www.minn ahacreek.ar <br /> Overall Project Description: f t /!� 1 x�� n � � �� <br /> Estimated Construction Valuation of Project(exctudi g land) $ $ <br /> APPLICANT ACKNOWLEpG�MENT: <br /> • Agrees to provide all information required or requested by the Building Departrnertt; <br /> • Certifies that the informatian supplied is true and correct Yo the best of his/her knowledge. Tha applicant reeognizes that they <br /> - are solely responsible for submitting a cpmplete�pplication bcing aware thaf upon failure tp do so, the staff has no alternative <br /> but ta rejeCt it until it is complete; <br /> � Some or all of the irlformation that you are asked to provide on this applicafion is Gass�eti by State law as ei�her pfiv2Ce 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. Confidentiai data is infortnation whfch generally cannot be given to either the publlc or the subject of the data. Our <br /> purpose and iniended use of this information is to annually update our records and records of other governmental agencies <br /> r uired b (aw. If ou rafuse to Su I the informati0n,the a lication ma nOt be issued. <br /> � s � �� �� s <br /> ApplicanYs Signature:� ❑ate: <br /> Last Updatad: 05-o4-2op9 <br />