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<br /> k � M,aiirng Adaress:
<br />��'� %��w�� PO Box oo ' Permit number. ;,��_ �/.�?- �i� 7
<br />' ` � Crystal Bay, MN 55323-DOoo Qate received:
<br />� _ ��' � � \ - �
<br />� ' ' �,r ,t�- � Received bY: �� L- ' �
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<br /> ��a N9 �� a���� s, , StreetAddress:
<br /> � � � � 2750 Kelle Parkwa � o 0 o a �
<br /> �: �,��, � ti �,
<br />�' ���, , �'k� �� Y Y ian.:r..vi..wTe,:: �`
<br /> `�s.rrEs�o4w Orono, MN 55356 ��
<br /> `�
<br /> I To:al Fe�; I g�
<br />� Main: 952-249-4o0D Fax: °52-249-4010 www,ci.orono.mn.us
<br />,. This appfication rorm must be completeo in rull and all required inr'orrr�ation must be suomitted. �
<br /> incompiete appficaiions wi(I be returned. (Please print) °�'
<br /> u�N=RA� INFORMATIOR: �.� �-� f . /� � �� �".--._.- ���
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<br /> '° Job Site Address: f5 ��/�.�� ,Q /��✓/'� /' ,�
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<br /> Will ti�is be a Parade mf Ffomes, Remodefers S' owcas� Home or other C�isplay Home? i] Yes t�o
<br />�` /f yes, a special event permif is required witn Poirce Department and City Council approval 6G days pnor ro the evenf. Snutfle bus servrce will be `
<br />��: required unless applicant demonstrates sufiicient on-site parking is avarlable. Non-permitted evenfs will not be allowed.
<br />�r
<br />,��, CONTRACTOR!;o.PPLICANT INrORMATl01�!: �
<br />`'` Name: �
<br /> �
<br />�� .
<br /> . S�ate License � � p p '�xpiration Qate: p�� ���9��G� �
<br />'r Lead Certificafion Number: Expiration Qate: � � �
<br /> (Tor work on homes that were construcfec'prior to 1978
<br /> Phone: _ 'ofiice) (cell)
<br /> ' Maiiing Address: ' � � City: ZI�: —o
<br /> �- C�ntact Person: c � - Appiicant i : ontractor / Homeowner (Cirde Une)
<br />��. �mail and/or Fax: � �����
<br /> �Ry
<br />�, �
<br /> PROPcR7'Y OWN�R INrORMl�TIO�
<br />,;.t, Name: �/ , �
<br />�� Phone(�ay): ,�� � �
<br />��;�' Addr�ss: ���/Y- ��,`��% �������,����/QJ CG�/�' 'c�ja�-���--9��Gfd
<br />� � icy. Z{P: �
<br />��; �mail and/or Far. �
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<br />�M1� ��
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<br />�,: PRC3J=�T IfV=ORM�I'IDR: �
<br />� Type of Project, I i I {�ny earth movement rra�require �
<br /> � ,�
<br /> � MCWD review&permits: �
<br /> ❑ Door(s) ❑ Remodel � ❑ Fire Qamage Ninnehana CreekVUatersned District(M�WD} ��
<br /> ¢. ' ❑ Re-roof, asphalt �Reaair ❑ Storm Damage 1E2G2 Ninnetonka Bivd
<br /> �.�
<br /> x>'i
<br />�.. ❑ Re-roof, ce�ar ❑ Restoration � o A Deephaven, MN 55391 ��
<br /> ❑V�at.,r Damag.. �
<br /> Pnone: 952-471-Q590 k�
<br /> ❑ Re-roaf, other(speci'ry) ❑ Sidin � : A ` o `�
<br /> g ❑ Oth..r (sp.,cify, � Fax: 52-471-Oo82 �
<br />� ❑Window(s) � www.minnehahacreek.orq ,�
<br /> ;= �:
<br /> ,� . , � ��
<br />��= Ove�all Froject �escripiiart: ���' /� r
<br />�� � � ��� ��
<br /> ,i' �siirratec# Corzs"truciion �afuaiivn of ?roject (ezciuciina �and) � � ��� �
<br />�~s AP� „af ^ �� � _ /_ � �� �.� � l",�7--j��U�.,� /�/�I/�"� � ��
<br /> �I�AI�T ��.F�iV01IV_�Q:��M�P�€T. � ;�;
<br /> � Aaress to provide ali inrorma'cion required or requested by tne Building Depariment; '��
<br />�~ ,�;:
<br />�~` • Certifies tnat the informaiion suppiied is true and correct to the best of his/her knowledge. Tne applicant recognizes tra: tney � �
<br />�} are solefy responsiole for submitfing a compfete apqficafion being aware t�at upon �ailur� to do so, tne staff has no alternaiive �"
<br /> but to reject it unfif i�is complete;
<br /> ,�
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<br />�, � Some or all of tne informafion that you are asksc to provide on tnis appiication is ciassiried by State iaw as eitner private or j �
<br />� confideniia;. ?rivate data is inrorrration wnicn gene;aliy cannot oG qiven to the pubiic but can be given to the subiect of the I ,.;
<br />�° da:a. Confideniial data is inrormafior whicn peneraliy cannot be qiven to eitner the public or tne subiec� o` tne ca�a. Gur I ��
<br /> �, i purpose and intended use of this information is to annualiy update our recores and re�ords o� otner povemmen;al agencies I �
<br />�_ ' reauired by taw. If ou retuse te sup�iv tne inrormaiion.tne aopiicatiq mav not bG issued.
<br />�" �/' /� �3,
<br />�.� I�Dpii�anf'S Sigra'ture: �G , . G�i'� � � Cate: ��� ����� �
<br />�Yw: ��t
<br /> a;, �ast Updaied: 08-Q9-2011 �
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