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MAY/14/2015/THU 03. 12 AM Elder Jones Building FAX No, 952 854 4909 P. 002 <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: 7 Q/ - OC40 I <br /> 0-1--i) <br /> PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: !/�� 15 <br /> Received by: JZO /1-61A� <br /> � k; �` Street Address: IQ <br /> ��[ <br /> , � o" 2750 Kelley Parkway Plan review fee: Iv[A. <br /> <y. s 'o y Orono, MN 55356 <br /> 36i qci <br /> ,_� Total Fee: ' <br /> Main: 952-449-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be su miffed." <br /> Incomplete applications will be returned. (Please print) le---40 <br /> GENERAL INFORM TION: <br /> Job Site Address: 7 <br /> q 0 01 d C S1 el o <br /> y <br /> Will this be a Parade of Homes, Remodelers Showcase Hor"rie or other Display Home ❑ Yes ❑ No <br /> if yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unlets applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION; <br /> Name: j t$P35 + 4 vy7 <br /> State License# THD At-Home Service, .Inc, e , <br /> Phone; I 2690 Cumberland Pkwy, Ste 300 (cell) <br /> Mailing Address: Atlanta, GA 30339-3913 ZIP; <br /> Contact Person: f Lie#CR268257 Ph. 763/542-8826 Iomeowner (circre on.) <br /> Email and/or Fax; f <br /> PROPERTY OWNER INF•R�QAT�N: i! � �4 Name: ♦ Cy� <br /> 74 <br /> Phone(day): _ , 5 119 <br /> / , <br /> Address: I • t • 4 lit ; / 4 Ci :11 Q j 64 4 ZIP: 5 6 ' <br /> Email and/or Fax <br /> PROJECT INFORMATION: - <br /> Type of Project; Any earth movement may require <br /> ' MCWD review&permits <br /> 1 Door(s) Q Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> �Window(s) p Repair El Storm Damage 18202 Minnetonka Blvd <br /> • Deephaven, MN 55391 <br /> ❑Siding , LI Restoration N Other:(specify) . Phone: 952-471-0590 <br /> iA J/ Fax: 952-471-0682 <br /> ❑ Re-roof ] Fire Damage Ali/(r //) S - www.minnehahacreek.org <br /> Overall Protect Description: /3 win efe,i4 5, p ,4- 'ty da l i s ' a d d,II/ o n -3 a /n$U /o , <br /> Estimated Constructio i Valuation of Project(excluding Ian ) $/ 8 y y 9 'lb ni.1 1,n? chi I <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide 'all information required or requested by the Building Department; <br /> • Certifies that the irjformation supplied is true and correct to the best of his/her knowledge, The applicant recognizes that they <br /> are solely respons ble 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 ail of the Information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Priv e 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 inten ed use of this Information is to annually update our records and records of other governmental agencies <br /> required by law. If4ou refuse to supply the information,the application may not be issued. <br /> Applicant's Signature: Date: <br /> Last Updated: 05-04-2009 <br />