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} t� ' ' <br /> ���� €�� �'�'��C� � �� ��. <br /> � , ��y�`N� � <br /> ���ic��r�g ��r�6� �.��a�������r� ��€- (�����a��r�c� f �e�c��a���� -� , �� <br /> v� <br /> (v�i€�aav���, �ioa�-s�, sic�i�g, re-raof, ��c.} ':� <br /> �, <br /> M,aiirng Aaaress: ' � <br /> '` %���.�- PO BOX bC� i Permit number: �Q! a'—� �� �' d <br /> /� ��� Crystal Bay, MN 5�323-0066 Qate received: �4--1� —/ �� <br /> i � � <br /> , „ <br /> � ,, it 'P� s.� Str.,,.tAddress: Received by: � <br /> � ��'� �� <br /> r� \�� �f,`"�' ��j 2750 Kelley Parkway � <br /> Pfan:reviewfee: � <br /> '�L� � a���v �� <br /> .rtEs�o� � Orono, MN 55356 <br /> ` � <br /> , � � Total;r=ee: 3Q�j , �(� � <br /> Main: 852-249-4000 Fax: 952-249-4010 www.ci.orono.mn.us ` <br /> _ * <br /> This appfication rorm must be completed in full and all required inr'orrraiion must oe suomitted. �.� <br /> ` fncompfefe appiicaiions will be returned. (Ptease print) � <br /> �� u��!�P.AL INFORMATIOR:� � <br />�k Job Site /address: �p ,5 f �/��:^ r � <br />��;�; Will ti�is be a Parade of Homes, Remodeiers Showcase Fiome or othe isp�ay Fiome? I 1 Yes ;_J P�o �� <br /> !f yes, a specral event permif is required wifh Pofice Deparrmen'and City Council approval 6G days orior fo tne event. Snutfie bus servrce wi!!be t� <br /> required unless applicant demons"trates sufr7cienf or-site parl<ing is avairable. Non-permitted events will not be a/iowed. � <br /> � <br /> ON'i"RACTO �l�PPLICANT INrOP.M,4T101�t: <br /> hame: _ �u t/' � <br />�; State License # Expiration Date: � ' � <br /> ��' <br /> Lead Certificafion Number: ���g�� �xpirafion Qate: � <br />,��r (r'or work on homes fhat were construcfe�'prior to 1978 <br />�; Phone: • � • ., (ofrice) (c�ll) <br />��� Maifing Address: � ' S'� ��iiy: � „ �-- � IP: — <br /> �: � � <br /> t Contact Persort: ����; Applicant is: Contra or / Homeowner (Circie One) <br />`"" Emai! and/or Fax: <br /> �, <br />}�;� <br />{;.; PROP�R'�"Y OWNER INFORM�TIO�t: <br />�, ; Name: ���1/�'/P���L-: <br /> a <br />�'`' Phone (day): � . <br />` .' Address: � " Cit ZIP� — <br /> _��o�v S��Lc-� !/i �� Y�����,�C/�� �S.� S'� � <br /> ti'' Email and/or Far. � ! � ��� � <br /> � <br /> l,;.: PR�J�GT INFORM�t,�101�: � <br /> ` Type of Project: � Any eartn movement rr,ay require �'� <br />��.: <br /> ❑ Door(s) ❑ Remodel o MCWD review&permits: � <br /> ❑ �ire Camag„ ii ,� <br /> Ninnshana Creel:V1�'aiershea Gistnct(MCWD) � <br /> � Re-roof, asphatt ❑ Repair ❑ Storm Damage ! 1 E202 Minnetonka Blvo � <br /> ❑ Re-roof, ce,�'.ar � ❑ Restoration ❑V1later Damage ' Deephaven, MN 55391 � <br /> Phone: 952-471-Q590 <br />�; ❑ Re-roof, other s e�i � <br /> ( p ..fy) ❑ Siding ❑ Other. (specify) =ar.: Q52-471-Oo82 �� <br /> ❑Window(s) i �Wminnehahacreek.orq ' <br /> �� <br /> Overall Project Descripiiar,: ; <br /> - ���.��� � <br /> =stirratecf Cor.struction �'aivauon or Proiect excfuciin Eanc! � �� <br /> � � <br /> $ <br /> � � � � <br /> � <br /> ��'�LICI-4I�T �,CbviVU11UL=Qa�ti�f�f�i: <br />� � Agrees to provide all inrormaiion required or requesied by tne Building Department; � ' <br /> � � <br /> ` • Certifies tnat the inTormafion suppiied is true and correc: to tne best or' nis/ner knowledge. Tne appfi�ant recognizes tra: fhey <br />.�,,- are sofeiy responsible for submitEing a complete apoiication being aware that upon failure to do so, tne s�aff has no alternaiive � <br /> but to reject it until i:is compfeie; I � <br />�. I • Some or all o` tne informa'tion that you are asked io provide on tnis appiication is classified by State iaw as eitner privat� or j <br /> conrideniiaL Private data is inrorrration wnicn generaliy cannot be given to tne pubiic but can be given to the subject of the i � <br /> data. Conr'ideniial da�a is information which gene�aliy cannot be giver. io eitner th� pubiic or the subjecf of tne cata. Our ; � <br /> ; purpose and intended use of this information is te annualfy update our records and re�ords of other aovemmental agencies � <br /> � reauired by law. If vou reruse to supoiv tne inTormaiion,the a�pfi�ation rrzav not be ISSL'�G. ; � <br /> � f n - <br /> � �%�/ 2i .� <br /> �.� <br /> App(i�anYs Sigr,ature: —� pato � �1 � <br />��;��� �ast Updated: 08-OS-2C11 � <br />'_��� <br /> '�'A <br />