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���y �� C��a�� c��-���o �o � <br /> ��`Ic�gr�g Pe�r�it App6i�a�iQn �or IV�ain�er�a�ce l �e�Q�ea�ia� �' <br /> �, <br /> . (winaov�rs, dvors, siding, �e-ro�f, e�c.} "` <br /> ,�� <br />'f Maiiing Address: �. <br /> n - ���.,d� PO Box 66 ��Permit��numbsr. � � � �� <br />�. /(� � Crystal Bay, MN 55323-0066 Date received: x�s <br />�'.� / �" �� � <br />�>�; I <br /> , , � , : �� <br />�.�. �� ��� ����.�,.� ,� � 5freef Address: �Received by�: � � � <br /> �'� '��' �'�' � 2750 Kelle Parkwa o „o �� <br /> ;�'���±h��o Y Y Planrrevi..wf,,,;: � <br /> � `�kEsxo4`' Orono, MN 55356 �� <br /> Total ree: �� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � <br /> ��: <br /> This appfication iorm must be completed in full and all required inTormation must be submitted. <br /> fncompfete appficaiions will be returnecl. (Please prrnt) °� <br /> GcNERA� INFORMATIOf�: �; <br /> Job Site Address: �j/ �Q/ � � <br /> / %' �'D � <br /> Will this be a Parade of Nomes, Remodefers Sh wc sa e Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a spec�a/event permif is required with Police Depar[ment and City Council approval 6D days prior to the event. Shutfle bus service will be <br /> required unless applicant demonstrafes sufficient on-site parking is available. Non-permitted events wil/not be allowea. <br /> CONTRACfOR/APPE.ICANT WrORMAT101�: <br /> f� Name: _ �G�G- -l�'tf�.2 G�.v57�.� c �i-e^� <br /> State License # a G - - `xpiraiion Qate: � ���j� <br /> Lead Certification Number: ��f���� � Expiration Date: ����`.g- � <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: � �✓' '- � - CJd (of�ice) (cell) <br /> Maifing Address � �,�� ��� S City: 7it` ,�'/ �y• IP: — �s� <br />�'`' Contact Person: � �, ��,� Appiicant is: ntract / Homeowner (CircfeOne� � <br /> '�,;: <br />- Email and/or Fax: <br /> F'g. <br /> PROPERTY OWNER INFORMATION: <br /> �• Name: _�!i�i�i'�G/-��/� � <br /> R,; Phone(day): ��'"-��lo� --lv�.�� . <br />.�; Address: T7�'�/p /'���� � City:�G���J� ZIP:j j��� <br /> ` ' G <br />�.' <br /> Email and/or Fax <br />��,.. <br /> PROJc�T INFOr?Me�aT101�E: <br /> Type of Project: Any earth movement may require <br /> ❑ Door s MCWD review& ermits: <br /> ( ) ❑ Remodel ❑ Fire Qamage P <br />�-�' Minnehaha Creek Watershed Disirict(MCWD) <br />� ❑ Re-roof, asphalt ❑ Repair ❑ Storm Qamage I! 1 E202 MinnetonKa Bivd � <br /> �Re-roof, cedar ❑ Restoration � Deephaven, MN 55391 � <br /> ❑Water Gamage � <br /> j��� ❑ Re-roof, other s eci Phone: 952-471-0590 <br /> ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 � <br /> ❑Window(s) � www.minnehahacreek.orq �� <br /> o,a <br />�r< Overall Project DescriptioR: ���o �,_��� 4 <br /> Estimated Construcfion Vafua'tion of Project (exciucfing Eand) y `7� ��� �d � <br />_ �� <br /> APPLI�AI�fT ACKNOWLE�GEMcNT: <br /> • Agrees to provide all informaiion required or reques'ted by the Building Department; •' <br /> I <br /> • Certir'ies that the information suppfied is true and correct to the best of his/her knowledge. The applicant recognizes tha± they � � <br /> are sofely responsibie for submitting a compfete appiication being aware tnat upon failure to do so, the staff has no al'ternaiive � � <br /> but to rejeci it unfif it is compfete; r;` <br /> �; <br /> :_� <br /> • Some or all of tne information that you are asked to provide on tnis appfication is classified by Sta"te law as eitner priva"te or I � <br /> confideniial. Private da,a is information wnich generaliy cannot be given to the pubfic but can be given to the subject of the i � <br /> da.a. Confidentia! data is information which generalfy cannot be given to eitner the public or the subject of tne data. Our ,�. <br /> purpose and intended use of this information is to annually update our records and records of other govemmental agencies I "=' <br /> re uired b law. If vou refusA �rp Iv the information, tne aopfication mav not be issued. " <br /> 4� <br /> i ._... " �,: <br /> ApplicanYs Signature: /�7� Da'te: �. � <br /> :.ast Updated: OH-09-2D11 <br />