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AUG/16/2011/TUE 04; 40 AM Elder Jones Building FAX No, 952 854 4909 P. 002 . City of Orono Building Perm�t Application for Internai Work (windows, doors, siding, re�roof, etc.) Mai�ing Address: Permit number: D//�d� 8g� O,¢Q�,� PO Box 66 Crystal Bay. MN 55323-0066 Date received: 8 � � Received by: St�esf Address: � � 2750 Kelisy Paricway Plan review f : �,�° Orono,MN 55356 �+ Total Fee: ��f', �O Main: 852-249-4600 Fax: 9`a2-249�46�6 www.ci.orono.mn.t�� This application form must be completed in full and all required information must be submitted. , Incomplete spplications will be returned. (Please print) GENERAL INFORMA710N: � D 3 �Q ` � / � n � Job Site Address: � �� Will this be a Parade of Homes� Remodei�rs Showcase Home or other Display HaFne? ❑ Yes ❑ No If yes,a spedal event permif is fequlfed with Pdlce DEpa�bnenf end C�y�CounG�approva!80 deys prior to the event. Shutde bua seivlce will be required unless appllcant demonstrales sulticient on�ite parking is avellab/e. Nan-permitted events w!lI rwt be allowed. CONTRACTOR/APPLICANT INFORMATION: , 1 b�f� �q £T ��l�I y� Name: x�At-�Tome Serviees, Ina `� State License# y69p �,�mbexland Pkwy, Ste 300 5� �y 5 - o�� Phane: (cell) Mailing Address: Cumberland Office Paz'k ZIP: Contact Person: Atlanta, GrA 30339-3913 lomeowner �c��i.o�) Emai1 and/or Fax: Lic#20268257 Ph. 763/ 542-8826 PROPEI2TY OWNER 11]�ORMA7'�ON:�a � j� n Name: C� 4 Phone(day): 3 � Q A n� . �� : Lbn q La�� Z,P: s's 3 s � Address: Email andlor Fax 'S� ? S ' 7 PROJECT INFORMATION: Type of Project• Any earth movement may requfre ' MCWD review 8�.permits ❑Doo�(s) ❑ Remodel ❑Water Damage . Minnehaha Creek Watershed DistricC(MCWD) ❑Window(s) �Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven,MN 55391 ❑Siding ❑ Restoration ❑Other.(speclfy) Phone: 952-471-0590 Fax: 952-471-0682 Re-roof ❑�ire Dama e 'nne h reek.o verafl Pro ect Descri tion: � - O , v / Estimated Construction Valuation of Pro'ect(excluding land $ 0 6 APPLICANT ACKNOWLEDGEMENT: . ABrees'CO provide all information required or requested bythe Building Departrnent; . CerBYes that the iriformation supplied is true and correct to the bs�t of his/her knowledge. "fhe appliqnt recognizes that they are solely responsibla for submitting a complete application being aware that upon fallUl'A to do so,the staiT has no eltemative but to reject it until it is�mplete; . Some or all of the information that you 8re asked to provide on ihis application is classified by St2te law as either private or conffdential. Private data is ir�formation which generally cannot be given to the public but can be gtv�n to the subJed of the data. Confidentiaf data is information which generally cannot be glven to either Che public or the subject of the dsta. Our purpose and intended use of this information is to annually update our records and recor'ds of other govemment�l agencies re uired b law. If u refuse to sup I the information, e a Ifcation ma not be issued. � � lr � l�t ApplicanYs Signsture: � Date: � � .../��J��J. /fC MA �IflA/� �