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SEP/22/2�11/THU 11 : 50 PM Elder Jones Building FAX No, 952 854 4909 P. 002 <br /> � —� <br /> � � <br /> City of Orono <br /> Building Perm�t Applicatiort for Mnternal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address_ Permit numbef: �l - //� <br /> g,��, PO Box 68 <br /> O, � Crystal Bay, MN 55323-0066 Date received: <br /> Strset Address: Received by: <br /> �� o� 2750 Kelley Parkway Plan review fee: <br /> . o�,� Orono,MN 55356 <br /> Tota) Fee: �`��� <br /> Main: 952-249-4600 Fax: 952-249�4696 wuMni.ci.orono.mn.us <br /> This application form must be completed in full and all required infolmation must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GEN�RAL INFORMATION:S�� �'Q�� d r,� ��/ �,� <br /> Job Site Address: r� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yea,a speaal avent pe�mit is�equlred with Police Depertment and Clty Council approvs/6U days priar ro the event. Shuttle bua seivice will be <br /> required unless appllcanr demonstrsfes sufficient onslt�parking!s availab/e. Non-parmhted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: THD At-Home Serv�ices, Tnc. 0 d� <br /> State License# 2690 G�imberland P1cwy, Ste 300 Q�'� q - G b y <br /> Phone: ����� <br /> Mailing Address: Cumberlaaad Office Park Z�P: <br /> Contact Person: Atlanta, GA 30339-3913 lomeowner {c�r�i.or,a� <br /> email and/or Fax: Lic�#2026$257 Ph. 763/�42-8826 <br /> PROPERTY OWNER INFO MATION: Q <br /> Name: 0� Q r �a h u <br /> Phone(day): ? - � Q Y� , <br /> Address: D o �/` Ci. : �0(�l� � zIP: s S 3 � � <br /> Email and/or Fax • <br /> pROJECT INFORMATION: <br /> Type of Project- Any earth movement may requlre <br /> � MCWD review�permits <br /> ❑Door(s) ❑ Remodel ❑Water Damage • <br /> Minnehaha Creek Wate1'shed District(MCWD) <br /> ❑�ndow(s) � Repair ❑Storm Damage 18202 Minnetanka Blvd <br /> Deephaven, MN 55391 <br /> ❑Siding ❑Restoration ❑Other(specify) Phone: 952-471-0590 <br /> F2x: 952-471-0682 <br /> f�e-roof []Fre Dama e www.minnehahacreek.om <br /> Overall Project Descri tion: u o 0 l�d +' .S l <br /> Estimated Construction Valuation of Pro'ect(excluding land) G <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all ir�formation required or requested by the Building Department: <br /> . Certifies tl�tat the ir�fortnation supplied is true and �rreCE to the best of his/her knowledge. The appUcant recagn¢es that they <br /> are solely responsible for submitting a compleis application being aware that upon failure to do so, the staff has no altemative <br /> but to reject it until it is complete; <br /> • Some or all of the information ihat you are asked t0 provide on this applicatlon is class�ed by Stete law as either private or <br /> cortfidential. Private dat2 �s iriformation which generally cannot be given to the publfc 6ut can be given to the subjeet af the <br /> data. Confiderttial data is informatlon which generally cannot be given to elther the public or the subject of the data. Our <br /> purpose and intended use of this information is to nnually update our records and racords of other govemmental agenCi66 <br /> r uired b law. H u re�Fuse to su I the informat' n, e a lication ma not be issued. <br /> .�'�� �ate: �T L�3��� � . <br /> Applicant's Signature_ � — <br /> �,..��,�w��• n�_nn_onna � <br />