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' �;�:. , � ra. <br /> �t�� �� ��-��� <br /> ������ <br /> �����g€�� ������ �,���������c� ���- �a��������� f �er�Q������ �� `���.�. <br /> '` - ��i�a����, �ic►ar�, si�ir�g, ��-rac�f, �cc.} <br /> �� Mailing Aadress: Permit number: p���a- G��� <br /> � %' '-�-y�v�.�- PO Box oo � <br /> /� �.,j <br /> �\ Crystal Bay, MN 55323-0066 Cate rrecei�ed: �f`�/-�� <br /> � � <br /> ���, ���, � ���-� s, � Street Address: �� � Received by.:�� � � �� �� <br /> \\'�� , µ"�� �� 2750 Keliey Parkway Planrreview fe <br />�;' �`��.ri�H�� Orono, MN 55356 <br />� To�al Fee: / ' <br /> Main: 952-249-4000 Fax: 952-249-4010 www.ci.orono.mn.us / ��{� �� <br /> This appficaiior rorm must be completeo in rull and all required information must be submitted. <br /> incompiete appficaiions wil! be returned. (Please print) <br /> ��t�=E2A� INFORM�,TIO�: <br /> Job Site Address: I 7�`�� ����o�i,�� ��, <br /> k' Will ti�is be a Parade of Homes, Remodeiers Snowcase Home or other f�isp6ay Eiome? �I Yss ❑ P�o <br /> 1f yes, a special event permit is required with Pofice Depanmen�and Crty Council approva!6G cays prior to fne even'.. Snuttie bus service wi!!be <br /> required unless applicant aemonstrates sufricient on-site par!<ing is availabie. Nor-Qermrtred events will not be aliowed. <br /> t �. <br /> - CON�RACTOR!APPLICANT INrOP.MATI �:� <br /> Name: �� 7�.,��, <br /> i " S;ate License # �xpiration Qate: ' �j �"; <br /> y Lead Certification Number: � A ��' <br />,`' -- - xpi�ation Qat,,: .�� <br /> ` (ror work on homes ffrat were constructed prior io 1 S78 — „ <br /> M Phone: (ofiice) � Z QS � (c�ll) <� <br /> Maiiing Address: � , City: ' ZIP: � <br />� ' Con,act Person: Apoiicant is: � l '� � <br /> �... �ow� Contra..tor ' / Homeowner (Cirde One) s,� <br />� cmail and/or Fa>;: <br /> K ;�;< <br /> ,: <br /> � <br /> f,, <br />�, PROP�RTY OWN�R INrORMA�I�t�: ; <br />�'� Name: � 9�✓�. C� �; <br /> G`� Phone(day): . <br /> Address: � � < j� (�. Cify: (�/11 ZfP� �' <br /> �,; <br /> �mail and/or Fax �,; <br /> �-; <br /> � <br /> r PRC3J��T INr-�RMlaTl01�: <br />; " Type of Project: � Any eartn movement rr�ay require <br /> I <br /> ❑ Door(s) ❑ Remodel � o i MCWD review&permits: ` <br /> ❑ Fire �amag., � <br /> j Ninnehaha Creek Ub'atersned District(MCW D) '` <br /> � ❑ Re-roof, asphalt ❑ Repair i ❑ Storm Damaqe I 15202 �inneionl:a Bivd `� <br />� � ❑ Restoration � Deephaven, MN 55391 <br /> � Re-roof, ceaar � � ❑VVater Gamage Phone: 952-471-Q590 <br /> �, Re-ro f, other(specify) ❑ Siding i ❑ Other: (specify) Far 952-47�-Do82 <br />�� <br /> ❑Window(s) i www.minnehahacreek.orq <br />� �.�� Ove�all Froject Descripfiors: <br /> �siirnatecE CoRstruciion �'afuaiion os ?roiect (�xciucfing ;and) � I������� � <br /> � ' A?PLI��AP�T �CE�NOVIlL�a:z�IVl��i i: <br />�, <br /> � Aqrees to provid� ali inrorma'tion required or requested by tne Buifding Depariment; 'k <br /> : � <br />�'. • Certir'ies tnat the iniormafion supp(ied is true and correct to tne besf of his/ner knowiedge. Tne applicant recognizes trat they '� ��; <br /> are solely responsible for submitfing a complete appiicafion being av„�aro that upon �ailure to do so, tne siaff has no alternafive <br /> � but io rejec't it until it is complete; �, <br /> • Some or all of the informafion that you are asked to provide on tnis appiication is ciassified b� S;ate iaw 2s eitner privat� or j ; <br /> confiaeniial. Private data is inTormation wnicn generali}� cannot be given to the pubiic but can be given to the subiect of the � � <br /> S;: I da"ta. Confideniial da;a is information which qeneraliy cannot b� giver to eitner tne public or the subiecf of tne cata. Our j �',` <br /> I purpose and iniended use of this inrormaiion is te annually update our records and records of otner govemmen;al agencies I � <br /> ' reauired b�� law. If vou reruse to the infor arion.the anafication mav not be issued. `t <br />'-z= <br /> Applican`.'s Siqraiure: Daie: � l _ <br /> �ast Updated: D�-OS-2011 <br />