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May-17-2012 08:20am From-CITY OF ORONO +9511494616 T-55T P.002/002 F-545 �nii �w cu�u n,:L uT,z� ,µ• � ' City of Orono 6uilding Permit Applic�tion for Internal Work (windows, doors, sidi�g� re�raof, etc.j Melling Addiess: pertnit number: a�-� '� � 0,�,Q,�,� PO�ox ss Crystal Bay, MN 55323-0066 pate reoafved: Sbeef Address: Re�eNed by: � � 2750 Kelley Pa�lcWay plan rovlew fe6: o�� Orono,MN 5535B � Tatal Fee: � ��2 Main: 952-249-4600 FaX; 952 249-4616 www.a_orono.mn.us �� This application form must be complebed in full and all required infonnatio� must be submitted_ , Incomplata appllcations wlll be retur�ad. (Pleasa print) , GENERAL INFORMATION:/�G � �Q��1 �/�� ' / � � Job Site Address: �� l't' Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No .. If yov,a speclal eva�pBnne�t is required wldl PoNce DepaKment end Cijy CovncN app�oval BO days priar to th�.averrt. Shutrle bus 8�avfcs wqFoe . iequiretl unresd 9AAlicent dOmonstrefes 6uf!'�nt or►-site parkinp 1s dv9�7dbk. NOIHp9ImVltsd avarfa will not de allowpd GONTRACTOR/APPL.ICANT INFORMATION; , Name: THX3.A►t-�ome Service9,Tna - State Ucense# L690 Cumberlat�d Pkwy, Ste 300 �� Phone: - � Mailing Address: Cumberland Office Park ZIP: Contact Person: ' Atlanta, GA 30339-3913 lameowner ��a o�.� Email and/or Fax: Y.�c#20268257 Ph. 763/542-8826 ,� PROP�RTY OWN�R INFOR ATION: Name: �4 L �l�t S � Phone(day): �� 0 ' s� S'f 3 � Y Address; L o !'/� Cf : �a v� c� ziP: Emait endlor Fax �r PROJECT INFORMA710N: 7ype of Projec� Any earth mov�emant may require MCWD revietiv 8 pemiits ❑poor(s) ❑Remodel ❑watar Damage nninnehaha Cresk Wa�torshed D(strlct(MCWp) �Nindow(e) �Repair O s��Damage 182oz Mlnnetonka Blvd D9�phavE�t1,MN 55391 ❑Siding ❑ResCu�ion ❑otr►er.(specity) Phone' E152�471-05�0 Faxc 952-471-0682 ❑Re-root �]�fre l]amagb www.minn�a ahacreek.ora Overall Projeat Description: 7 v� e d �.I /Y) /!) S , Fstimated Co�truction Veluation of P�oject(excluding 1 ndy S �/�7 a y _. AppLICANT ACKNOWLEDGEMENT:: • ,qgrees to pravide ao Ir�formation�quired or requested by ihe Building Oepartment; � . Cartlffes U1at the infornnetlon supplled is true and carroct to the best o1 hls/her knowledga. 7he F�ppllcarrt recognlzes that they are Solely responsible for submtttlng a comp�at6 appl'�cadon being eware that upon failure bo do so,the staff has no alternative but to reject h until it is complete; . Some or all oi the Informadon tha[you are asked to provide on this 2pp�cation is cl2esRed by State law as either p�lvote or corrtldential. Prlvete data IS if�ormatlOn which 9enerally cennat be 9ivan to 1he public but can be given to the subject of the date. Confldential data� Is inform�tion which generaly c�nnot be glven 'to either the public or �he subJeet of the data. Qur purpose and irrte�ded use af thls icrforrr►atJon Is to annusly update our rec�ds �1d records of other govemmental agenci� uired b law- If U rafuse to su I the i�orcnattOn.the ticaGon ma not ba issued. � Date: 7 l L ` � � Applicant's Signature: — t,ast UpdBl�d_ 06-04-2fJ08