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- , .. �r< �"�`,�e � i` <br /> ���� €�� ����c� <br /> _ ���. <br />, . . . � �����er�� ���r��� �,���������� ��r �������t�nc� l ��c�c�����a� . �� <br />° �v�i�aa�.�s, �ioo€-�, �iair�c�, ��-raof, ��c.} <br /> �� <br /> i� M,arlrng Aaaress: I Permit number. ���� -�d �' <br /> %'-�w�� PO Box n6 <br /> �� Q Crystai Bay, MN 55323-O�ci6 Date received: —Z � �.' <br /> �;, <br />' ��� ��'�-�'` a. Sfreet Address: ' Received by: �� <br /> � � E;� <br />, \�'����y�,�y,�'�,�;� �� 2750 Kelley Parkway Plan.reviewr'ee. �� <br /> y:� `�.rrEs�o�w Orono, MN 55356 � �� � <br /> 1 �`' <br /> To�al;Fe�: ��'/ � �s< <br /> Main: 952-249-4000 �ax: 952-249-4616 www.ci.orono.mn.us Y�' _ y€;� <br />' � This applicaiion rorm must be completed in full and all required inforrration must be submitted. � <br /> ' incompfete appficaiions will be returnecl. (Please prrnt) �� <br />���� �ENERA� INFORNEATIOf�: � t; <br /> '� Job Site Address: � � 1, � <br /> c:' - � <br /> Will this be a Parade of Fiomes, Remodeiers Snowcase Home or other Disp�ay Fiome? ❑ Yes P�o 'f <br />�{x lf yes, a specral event permif is reouired with Police Deparrmenf and City Council ap,proval 60 Cays orior to the event. 5huifie bus se ice will be � <br />� required unless applicant demonsirates su(iicient or-site parking is avairabte. Non-permitted events wil/not be allowed. �� <br />��;,` `:� <br />� . CONTRACTOR!APPLICANT INrORMA�l01�: � _) �� <br />� ; fvame: ��"Z.-- �� Lf ,�L.�t �'�.� ,���.. � <br />�<. S�aie License # �� �� 3��—� Expiration Date: " � <br /> F'` Lead Certificafion Number. � � Expiration Qate: � <br />� � <br /> : (ror work on homes fhaf were constructed prior "o ?978 <br />�� Phone: /a `- a, 1 " C�� GL/� ��f71C?� �C���} �. <br /> Maiiing Address � J�,�J�V� City: ZIP: �� <br />�=j; Contact Person: Applicant is: Contracior / Homeowner �c���ie Une) <br /> cmail andlor Fax: — �- <br /> �:, , <br /> rt � PROP�R�'Y OWN�R INFORM TIOt�: � <br /> Name: � !,� � j�'j-��.�r � �'e- � �� � <br /> Phone(day): . <br /> Address: / �G�` �/�j�u ��� Ci'ty:�`��'�� ZlP� <br />�.�� Email and/or Fax �.� <br /> _ � <br /> Pr2E3J�GT IN=ORMEeTIOn: �%� <br />� � Type of Project: � I � <br />� � Any eartn movement tr,ay require <br /> � ❑ Door(s) ❑ Remodel I MCWD review�.permits: �� <br /> ❑ Fire Qamage � Ninnehaha Creek VVatershed District(MCW D) �' <br />�� ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage � 18202 Ninnetonka Bivd '�� <br />��t ❑ Re-roof, ce�ar ❑ Restoration ❑VVaier Damage I Deephaven, MN 55391 :�. <br /> Z - Phone: 952-471-Q590 <br /> Y ❑ Re-roof, other(specify) �Siding ❑ Other: (speci"ry) j rar,: °52-47"�-Oo62 � <br /> °': ❑Window(s) i www.minnehahacreek.orq i <br /> ' � i <br /> L% , <br />.�-r Ove�al! Froject DescripfierR: <br />;`, <br />��-'. __=siirratecE Cor.s�rucfion �'afuaiion o� ?roject (excfuciing �and� � � (c � � <br />� � <br />��� �4PPLI��I�T �Ci�i�EaV19L�Q��M�i�i: � <br /> � Agrees to provide all inTormafior required or requested by the Building Depariment; <br /> • CerfiTies tnat the information suppiied is true and corre�t to the best or' nis/ner knowledge. Tne appficant recognizes that they I <br /> are sofely responsibfe for submitiing a compfete apoiicafion beinq aware that upon �ailure to de so, tne staff has no alternafive <br /> but to rejec't it unfil i:is�ompieie; <br /> � Some or all of the informafion t'r�at you are asked to provide on tnis appiication is ciassified by S;ate iaw as eitner private or i �'� <br /> confioeni�af. Private da'ta is inTormation wnich gene;ally cannot be given to tne pubiic but can be given to the subject of the <br /> cta.a. Confideniia! data is informa n which generaliy cannot be given to eitner the pubiic o: tne suoject of tne da;a. Our � <br /> purpQse and intended use of th' i formafion is to ann�ally update our records and records of other qovemmen,al agencies I <br /> reauired by law. If vou reruse s pi the informatio tne piic on mav not be issued. ;�� <br />��: kppii�anf's Signature: �-- �,,.J Date: '-''� # <br />�. � � ��.�_ � <br />�s� '_ast Updated: 08-09-2D11 °� <br /> . <br /> . <br /> _ �x <br />