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JUN-20-2011 02 :57 PM WALKER, ROOFING 6512510916 P. 01 <br /> __.._. .a . ... ...�� �pr�r���ai�vi� ��� ����ernal WOI'K <br /> •► (windows, doors, slding, re-roof, etc.) <br /> 4 ��•==��•— MelllnpAddr�ss: <br /> �g�� PO 6ox 66 Permlt number; 026//- pZ� 7 <br /> � . � Cryetal Bey, MN 55323-0066 Date received: <br /> � <br /> � � ;°t:. �� Stre6tAddress.• Received by: <br /> / <br /> 2750 Kelley Parkwey Plen review fee; <br /> �+�� � Orono, MN 55356 <br /> .Main; 852-249-4900 Fax; 952-249�816 www,ci,ornno.mn 1A TotelFee; � ��� j� <br /> U <br /> This epplication form mu�t be completed in full and aii required information m�st be ubmitted, <br /> Incomplete eppllcatlo�a wfll be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Addreas; 2 I � ' T <br /> WIII thia be a Parade of Harries, Remodvlers 8howcase Wome o�other Dlsplay ome7 Yes o <br /> N ya*, e speclel swnf pemrlt la roquirod w/fh Pollce Department end Clty Councll epproval QO days pnar to the event. Shuttle bus servlce wUl be <br /> requlred unle8s eppl'icanf demonstretes suAYclent on-sl�e perkinp is evallable, Non-pemrittod eVenta wlll nof be ellowed. <br /> CONTRACTOR!APPL�CANT INFORMATION; <br /> Name: � � �y, <br /> State Licenae# �,�'�f� Expir�tion Date: /2 <br /> Lead Certificatlon Number: .- — - �V Expir�tion Date� <br /> (for work on homas that wsro consbucted prior to 1678 ,� 07�ZS <br /> Phone: ��� ( .- ',��,t � u q t 0 (office) �� <br /> M�iling Addree�; 2 u Q�D � Clty: c,,� Z�p; ' <br /> Contact Person: Applic�nt is; nt�a / liomeowner �c�►��e o�a� <br /> Emall andlor Fax; �,tif � , � <br /> PRQPERTY OWNER INFORMATION; <br /> Neme: � N � <br /> Phone(day); 51 � � - <br /> Address: t Its 1' L�►.,� �. CitY; ��e►J ZIP; �� (a l� <br /> Emeil and/or F�x <br /> PROJECT INRORMAYION; <br /> Type of Projoct: Any oorth movemant may requlre <br /> ❑ Door(s) ❑ Remodel ❑Weter Damage MCWD roview 8 permlts: <br /> Minnehwh�Creek Wetershed District(MCWD) <br /> ❑Wlndow(s) �&epair ❑ Storm Damage 16Z02 Mlnnetonke Blvd <br /> ❑ Siding ❑ Restoretlon ❑ Other, (spacly) Deephaven, MN 55381 <br /> ,►�Re-roof ❑ Fire Damege Phone; 952-471-0590 <br /> v — <br /> Fex� 962-471-0882 <br /> �kY,frilLlnehahacreek ora <br /> _Overall ProJect Descrlptlon: �-�p�L. �� �}.�/,p �� �C a.� �„�„ „ y�j L,,�p,�py�„Er SN�. <br /> Estlmeted Constructlon Veluatlon of ProJact(excluding land) $ � �p �$�, I � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agreee to provida ell information required or requeeted by the Bullding Depertment; <br /> • Certlfles that the inform�tlon supplied Is true �nd correct to the best of hia/her knowledge. The eppllcant recognizea thet they <br /> are solely respohsible For submitting a complete �ppllcation being �w�re thet upon fallure to do so, the staff h�s no alternative <br /> but to reJect it untll It le complate; <br /> • Some or ell of the inFormetion that you ere asked to provide on thla epplicatlon le clessifled by Stste law ae elther prlvete or <br /> confldentlal. private dete la information which generally c�nnot be given to the public but can be given to the subJect of the <br /> dete. Confidentl�l date la Informetlon which generelly cannot be given to either the public or the subject of the data, Our <br /> purpoee and intended use of this informetlon ie to annuelly updete our records and records oF other governmentel �genciea <br /> re uired b lew. If ou refuse to eu I the)nform�tlon the a lic�tlon me not be Iseued, <br /> Applicent'e Sfgnature� Date; v � � <br /> Laat Updaled� 03-01-2011 <br /> �(..�A� �� -�� U� S� N � rh 8� , <br />