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<br /> , �r�E�d��� P��r��� �,�������e�� �c��- �`���r��:���r�c� � ���c��������
<br /> . �iM9filC�C�VI.��, C�C�UCS, SP�I�C�, �'�-CC7�C�T', E4e.C.�
<br /> ,��� M,ai(ing Aaaress: � �/� _ �
<br /> � Perm�t numb�r. -� �
<br /> ; '� ��- �\ PO Box 60
<br /> � � \ Crystal Bay, MN 55323-0066 Qate�received:
<br /> �r I
<br /> ��J y�'` Receiv�d b /� � 7 �
<br /> �, � y� �,� ;� � Street Address: Y���� � � F-�1�.I�� � �
<br /> �'� � ��"�� ��/ 2750 Kelley Parkway �
<br /> �`�'�; � J Pfan:review fee:
<br /> `�.ri�sHog�' � Orono, MIJ 55350 � � �
<br /> Total:Fee:
<br /> M,ain: �'52-249-4000 Far.: 952-249-4010 wwv,�.ci.orono.mn.us
<br /> This aoplication form must be completeo in full and all required inforrriafion must h� ��� �tt�� /S� ��
<br /> incompfefe appficaiions wil! be returned.. (Please pn ��
<br /> G��f�P.�,� IfVFOP.M�,TIOR: - `
<br /> Job Site �ddress: ���� � � � ������ �
<br /> �,5 ��.�„�/���� "��i%'✓/i�' /;- � �� �
<br /> Will ti�is be a Pa�ade or Fiomes, Pemcsdeiers SiSowcase Home or o�her �isp�ay'riome? I � Yes I�P�o
<br /> If yes, a special event permit is required with Po(ice Deparrment and C,ity Counci!aoproval 60 days prior ro fhe event. Snuttle bus se`rvrce wil!be
<br /> requrred unless applicant demonstrates sufiicient on-site paricing is available. Non-permitted events will not be allowed.
<br /> �ONTRACTOR I;a,PPLICAI�T INFOP.IViATIOt�:
<br /> fvame: � �
<br /> ��� .., ���r2f' �� i
<br /> S,ate Licsrse � �-�> �ry e�� ` Expiration Date: ,�,�o'��?�j�
<br /> Lead Gertir"ication Number: � Expiration Qate:
<br /> (r"or work on homes fhat were constructed prior ia 1978
<br /> Phone: _- --� �- _ � ofrice) (c�ll}
<br /> Maiiinc, Address: � ' -- ; r---� �_ City: ZIP: o .�.�
<br /> Contact Person: �c � - Appficant is: ontractor / Homeowner (�ircfe Gne)
<br /> Email and/or rax: ���' � � ' ' _ ,� �, �
<br /> r;i i- . /���
<br /> PROP�F�i Y OWN�P. INF�JFZMATIOI�:
<br /> Nam�: �� /'r/-�"%%���-
<br /> � i'= /- .������� �
<br /> Phone(day): --��,� � ° i .� ' �-7--� �i/ �
<br /> �
<br /> Adciress: � � , � �i,�QG!/��//-�C��✓�l Cti%� 'd�o�-�J��-r'y�i�
<br /> �tY� ZfP:
<br /> Email and/or =ar,
<br /> Fr?QJc��" I{V�C3RN6�eTlOF�:
<br /> � 3ype of Froje�fi � L�.ny earth movement rra�require
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Qam,age MCWD review &permits:
<br /> Ninnehana Creel:Watershed District(MCWD)
<br /> ❑ Re-roof, asphalt �Repair ❑ Storm Dama e �
<br /> 9 � 1 E202 �innetonf:a Blvd
<br /> � ❑ Re-roof, cecar ❑ Restorafion ❑ VUater Damage � Geephaven, MN 55391
<br /> Pnone: 952-471-0590 �
<br /> I ❑ Re-roof, other(speci'ry) ❑ Siding ❑ Other. (specify) �a;:: 952-471-Oo82
<br /> I L1 Window(s) � www.minnehahacre�l� orq �
<br /> O�re�alf Froject Descripiior.: .,f�!�� /��rt/ �.� ,..�'/d,%�� �; ������ � �� 'j' �� ��, �
<br /> �siirr,atee� Cor.s"tru�iion �°aivaiion o� Proiect (exciuding fand) � " �
<br /> � ��f� ��r� � �, / ��.0 �� /��I/ �i`�f--�%%'/'fi` ���G'��r���ii r)
<br /> '4?P!i�/-�hkT �$�...i�f�OVIlL�Qv��Vf��(: ,
<br /> � = Agrees to provid�ali inrorrnaiion required or requesied by the Buifding Department;
<br /> � Cer�ir"ies trat tne inrormaiion suppiied is true and correct to the best or' nis/ner knowledge. Tne appficant recognizes trat they I
<br /> I are sofely responsible for submitiinc a compiete appficafion being aware that upon failure to do so, tne siaff has no afierraiive
<br /> but to rejec't i;untif it is compiete;
<br /> I � Som� or all of the informafion tnat you are asked io provide on tnis appiication is ciassiried b�� State iaw as eitner rivai� or I
<br /> conrideni;al. private da;a is inr"ormafion wnich qene;aliy cannot b� given io tne public but can be qiven to fie subiect of ihe
<br /> � daia. Conr'ideniia! data is inrormation wnicn gene;ally cannot be given io eitner the pubii� o� th� sub,iec� o� tne cata. Our j
<br /> j ourpose and intended use of this informaiion is to annually updat� our records and recores of otner governmen;ai agencies '�
<br /> reauireG� b�'i2VV. ��VOLJ �AT115�t0 SUppIV thE InfOfffSBTIOR, tflE aDpltCdT10f1 fT12V f10i bS ISSU�d. �
<br /> �1QPIICZfI`.'S SI�i�BiU�p' /C'/ C�` !�. ! ��'�//� / n^ `- � /v;�
<br /> � �. .
<br /> ... , / -! f/G i ✓/' U' � 1 '�j � �aTa . �� G•�,�'"���/.✓
<br /> L2S'�Q�a?eC. D�'-D5-2p,., `_
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