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���y �f C��a�� <br /> ��6�c�gng �'e�rr��� ��p6i�a�iQn �ar tt�air��e�a�ce / F�enQ�a��o� <br /> (winaou�s, cioors, siding, re-roof, e�c.} '�` <br /> W� Mailing Address: j <br /> ���,d,� � PO Box 66 � Permit number: o2�S��-07 9 <br /> �: a Crystal Bay, MN 55323-0066 i Date received: � ,ZD-1,7.� <br /> . I t� �,` Q n <br /> 3 � <br /> I`� I�� � ; r i �, �1�� ' Street Address: Received by: <br /> `�� � ;F?"�� �� 2750 Kelley Parkway Planrreviewfee: <br /> '�'��.��SH��w Orono, MN 55356 y� <br /> Total Fee: f1 / OJ"�, �.S <br /> Main: �52-249-4000 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This appfication rorm must be completed in full and ali required information must be submitted. <br /> fncompiete appiicafions will be returnecl. (Please print) <br /> GEN�RAL INFOR�ATIO�f: r <br /> Job Site Acidress: � � -�7 f P�".E— �.( !� • �'� „' �L ,��j�� � <br /> Will this be a Parade of Nomes, Remodefers Showcase Home or other Display Home? U Yes ^ o <br /> !f yes, a specral event permit is required with Police Department and City Counci;approva!60 days prior to the event. 5huttie bus servrce wil!be <br /> required unless applicant demonstrates sufiicient on-site parking is avai/able. Non-permitted events wil/not be allowed. <br /> CONTRACTOR/APPLICANT INrORMATI�1�: <br /> Name: --� <br /> S;ate License # Expiration Date: <br /> Lead Certificafion Number: Expiration Qate: <br /> (for work on homes that were coRsfructed prior to 1978 <br /> Phone: (ofrice) (cell) <br /> Maifing Aadress: City: ZIP: <br /> Contact Person: Appiicant is: Contractor / Homeowner (Circie One) <br /> cmail and/or Fax: <br /> PROP�RTY OWNER INFORMATION: <br /> Name: J�/�"� '� �{� I -P <br /> Phone (day): ��L - ��'7� • 7�I C7 (G'��� �C�%� ���� - �% �=3 � <br /> Address: �l�7 S �2'�eS�f- LFS� '�-_ City: C's cti� ��� ZIP: ,S� ��c �� <br /> Email and/or Fax ' <br /> PROJ�CT INFORM�t,TlO�: <br /> Type of Project: ', Any earth movement rrzay require <br /> ❑ Door(s) ❑ Remodel I ❑ Fire Qamage I MCWQ review&permits: <br /> Ninnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt [-�pair ❑ Storm Qamage 18202 Ninnetonka Bivo <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-Q59� <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (soecify) � Far 952-471-Oo82 <br /> ❑Window(s) ���,(� J�k J 4 S�--�v�;:���[S �"'�`^'�minnehahacreek.orq <br /> Overal! Project Description: j t.;�t���- �'�E'�'"� Ce�����.- ��<'�,<� ��°�r��s" �` �i'����/�s� G�Y� 17�7`�rd4.G "���,f� <br /> �sfirr�ated Construcfion Vafuafion of Froject (exciuding iand) � yL 6O0 `J <br /> APPLICAI�4T ACKNOWLEDEa�McM1E i: <br /> i • Agrees tc provide all information required or requested by the Building Department; <br /> � • Certifies tnat the informaiion supp(ied is true and correct to the best of his/ner knowledge. The applicant recognizes that they � <br /> are soieiy responsible for submitfing a compiete appficaiion being aware that upon failure to do so, the staff has no aliernafive � <br /> but to re}ect it unfil it is compiete; i <br /> i • Some or all of the inTormation that you are asked to provide on this application is classified b}� State !aw as either private or <br /> ' confideniiaf. Private da;a is inforrr�ation wnicn generalfy cannot be given to the pubfic but can be qiven to the subiect of the <br /> ; data. Confideniial daia is information whicn gene�aliy cannot be given to either the public or the subjec't of tne da;a. Our � <br /> ' purpose and intended use of this information is to annually update our records and records of other qovernmen,al agencies � <br /> reauired bv law. If vou refuse to sup I the information,tne aopiication mav not be issued. � <br /> , <br /> ApplicanYs Signature: - -:'�� , G c.�� <br /> � -r/� Qate: C� /�:��U %/ �- <br /> Last Updated: OS-�9-2D11 <br />