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<br /> ����c���� E��r�E-r��� �,���������� ��� �'`���r�����r�c� � €���e�������� ,,
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<br /> ��aoc�dc��.F�, ciaor�, �i�ir��, ��-rae�f, ��c.} �f_�r ,—i�tlC
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<br /> M,arirng Aadress: i � �� � � ����
<br /> "�-�-w�� PO Box o6 Permit numb�r. �-� .� c, ,�
<br /> �� � (�� Crys;al Eay, MN 55323-OQ66 I Qate recei�ed:
<br /> �y
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<br /> �a �'�� �� ;� I StreetAddress: f.Received by:,� __�' ��
<br /> �� ����' ti ,
<br /> ��� � ��/ 2750 Keliey Parkway Pian:revisw:fee-
<br /> �``�.�Es��`�`'� Orono, MN 5535n
<br /> To.al Fes: : ��v� - � �
<br /> M�ain: �52-249-4000 Far.: 852-249-4010 www,ci.orono.mn.us
<br /> Tnis appfi�aiion form must be completed in full and all required information must hG ���hm;ttA�+
<br /> incornpiete anpiica"tions wilf be returned. (Please pr, � � -f�� �'�
<br /> G���RAL INr=ORMATl01�: -
<br /> ,�ob Sit� �iddress ����.-/�,✓�✓�--��r `%/4i��''�/��y��`/��-=y �,�j�� .. __ �/
<br /> Wiil tnis be a Parade of Fiomes, Rem�defers SKowcase Home or o�her €3isp�ay�me? � Yes �60
<br /> If yes, a soecral event permrt is required wrth Po(ice Departmenf and City Council aoproval 60 days prior ro the event. Shuftle bus servrce will be
<br /> requrred unless applicant demonstrates suf�icient on-site parking is available. Non-permitted events will not be allowea.
<br /> CONTRAGTOR/;4PPLICANT INFOP.M�4TIOR:
<br /> fvame: -��_�?���%�����`Z��,�j��/�% �/% r"�ir"'
<br /> State License # ,��) � �'r�� �� �xpiration Cate: �y , �������
<br /> Lead CertiTicafion Number. Expiraiion Cate: '
<br /> (Tor work on homes fhet`were construcied prior ro 197B
<br /> Pnone: . � �- _ � of�ice) (c�llj
<br /> Maiiing Address: - , �- � y�,- Ciiy: ,�� ZIP: d :�
<br /> Contact Person: �c , �` " I - Applicant is:- ontra:^tor / Homeowner (Circle Gne)
<br /> �mail and/or Fax: ' ` ' '
<br /> ����� i � � �� �� ���
<br /> PRO?�F�TY OWN�P. INFORMwTIOP�:
<br /> Name: ��;�!�,%��i''�f �7 ��'��j�����i�
<br /> Phone y): � ' �
<br /> Hd ci res s�a /�����'r-�-� C�c>'/PG�`'"l`.-,�!'����,�'. C i'i/ �6/°`..�—��JZ,_rj�%��'":
<br /> � `�=itY: �� � ZfP:
<br /> Email and/or Far.
<br /> P2QJ�C'� I�IFC��ZI1P,�el'IJR:
<br /> ! Type of Project: I k.ny earth movement rra}�require
<br /> ' i
<br /> � ❑ Door(s) ❑ Remodel � ❑ r=ire Damage MCWD review&permiis:
<br /> Niinneraha Creel:Waiershed District(M�WD)
<br /> I ❑ Re-roof, asp�ait � ,� Repair ❑ Storm Gamaqe � 1E202 Ninnetonka Blvd
<br /> ' ❑ Re-roof, ceaar ;I ❑ Restoration ❑UUater Gamage 1 D�ephaven, MN 5�391
<br /> ❑ Re-roof, other;speci'ry) I ❑ Sidin a,., ; �„ Pnone: 952-471-0590
<br /> g ❑ Oth.,� ,sp,,,,ify) i r=ar: 952-471-Oo82
<br /> ❑Window(s) I i www.minnehanacreek orq
<br /> O�e�alf Froje�t GsscripiiaR: �;�>..•� _ - � . /�
<br /> ; � .�l-�" /��� � .. � - . _� �. ��-� , �' .,�i%
<br /> �stirr�a�e¢� Cor.sfrucEion ��aivation o; Froiect (er.cfucfing �and} $ � �,�
<br /> .
<br /> ;L}f� ��� �.�!. �j� �� f����"�'/--- ,C_-�;%,,,-,�. �-,/'����L�//`c
<br /> �aP?!IC/�t�T �Ci6i�0in9L�Q�.��Ni�F�i: / ,
<br /> I d Aare�s to provid� all inTorrnaiior reouired or requesied by the Building Gepartment;
<br /> I � �erfir"ies that the informafion supplied is irue and correci to the best or' nis/her knowied � Tne a li�ant reco nize p II
<br /> I are sofel � re � g� PP � g s tnat th„y
<br /> ) sponsibl.. for submitiino a complete appficaiion being aware that upon Tailur� to do so, tne staff has no alierrative
<br /> bu:io rejec't it unfil ir is compleie;
<br /> ! �
<br /> e Some or all of tne information tt��a± you are asked to rovide on tnis a p(ication is cassiTied b� ^� � I
<br /> I P P � ��ate iaw as eitner privai., or ,
<br /> j conrideniial. ?rivate data is inrormation wni�h aeneraliy cannot oe aiven io tne pubiic but car be given to the subiecl oi tne i
<br /> ! da:a. Conr"ideniial data is information whicn peneratiy �annot be given to eifner th� public or tn� subiec: or tne ca�a. Our i
<br /> i purpos� and in'tended use o� tnis inTormaiion is to annuall}� updat� our recores ano recoros c� otner govemmental agencies '
<br /> reauired b�� �aw. If vou refuse to supofv tne inr'orrraiion.tne ao�ii�ation rr,a�� not be issued.
<br /> kppii�anf's SiQrature: �� </, /�'1�/,� �' _ / - �- %`'-
<br /> , �%`= �j��, c����`% � , .��_ ^ai�: � ''� u r'i;�
<br /> (/� .. �_-
<br /> _as`�a�ated: D�-09-2D"�
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