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,APR/N/2013/TUE 01 : 12 AM PAX No. 952 854 4909 P. 002 City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number. ok 13—O 0.215- 0" � Crystal Bay,MN 55323-0066 Date received: Street Address: Received by: 5 2750 Kelley Parkway Plan review fee: Orono,MN 55356 Total l=ee: � 36�• ! Main. 952-249-4600 Fax: 952-249-4616 www.ci.arono.Mn.us This application form must be completed in full and all required Information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION:y G $ Nd i--1A 51) 0 to D/ Iva, Job Site Address: Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes ❑ No !f yes,a special event permit is required with PorCe DapaNment and City Council approval 60 days prior to the event. Shuttle bus service will be required unleas applicant demonstrates suffldent on-site parking is aveilabla. Non permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: Joc% Qf9lgSo y7 State License# THD At-Home Semce, Inc, Phone: 2690 Cumberland Pkwy, Ste 300 (cell) Mailing Address: Atlanta, GA 303393913 ZIP: Contact Person; Lic#CR268257 Ph. 763/542-8826 lomeowner (clrae One) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: ( Y Phone(day): S b Address: q 6 15- N. 5A b f)1 City: Mo a n d ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review&permits Door(s) ❑Remodel ❑Water Damage Minnehahe Creek Watershed District(MCWD) Window(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd beephaven,MN 55391 ❑Siding ❑Restoration ❑Other.(specify) Phone: 952-471-0590 Fac: 952-471-0682 ❑Re-roof ❑Fire Damage www.minnehaha r k.or Overall Project Description: d r Estimated Construction Valuati n of Project(excluding land) $ 20 3 / b APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all Information required or requested by the Building Department; • Certifies that the information supplied Is true and Correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies required by law. If you refuse to supply the information,theapplication may not be issued- -� y� 11-3Applicant's Signature: �--, Date: Last Updated: 05-042009