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���� �� ��c��� <br /> t ��c���r�� E������ �,���������� ���- f�a�r���r�a�c� � ��c�������� <br /> r <br /> (v�i�cio�p�, �iaa€-�, siaic��, ��-ra�f, ��c.} <br /> M,ai/ing Adar-ess: <br /> ;���� PO Box oo j Permit numb�r: p2��p2—d/2/ <br /> �� �� Crystal Bay, MN 55323-0066 ' -Date received: � ��O,�'���� <br /> � � ' �r.�. <br /> �� ,-.rY � � Received oy: <br /> ��,� ��t���;y Srreet Address: � � � � <br /> `\'���M�'�{�f�`'."��,�� ��/ 2750 Keliey Parkvray <br /> � ��rr4w Orono, MN 55356 � Pianrreviewfee: <br /> ��Esxo � <br /> Main: �52-249-4000 �ax: °52-249-4016 www.ci.orono.mn.us i Total:Fe�: �0�,p� <br /> This application form must be compl�ted in full and all required information must be submitted. <br /> fn�ompiete appiicaiiorts wil! be returnea. (Please prrnt) <br /> ��h'=r.A! INr=ORMATlO�: <br /> Job Site Address: '� �� ,^�I,J�'` 1���� <br /> Will tn:s be a Parade or Eiomes, P.emodefers Showcase Fiome or other Disp{ay Fiome? I� Yes �fo <br /> /fyes, a specral event permif is required with Fofice Gepartment and Cit}��ouncil approva!60 days prior to the event. 5nuttie bus se rce wil!be <br /> required unless appiicanf aemonstrates sufiicient on-site parking rs availabls. N'or-permitted events will nof be aliowed. <br /> CONTRACTOR/;a,PPLICANT INrOP.MATIOf�: r <br /> Name: :� - <br /> State License # ' �(�' � � cxoiration Cate: '�' '� ' � <br /> Lead Certirication Number. U -'-� Expirafion Cate: �-� <br /> (ror work on i�omes thaf were.,onstructed prior to 1978 <br /> Phone: ' — � (ofiice) (cell) <br /> Naiiing Address � City: ZIP: 1—• <br /> Con;act Person: ' � Appiicant is: Contrac / Homeowner (Circfe ne) <br /> Ernail and/or Fax: - <br /> PROP�R i Y OWN=R INrO �ID�t: � _ <br /> Name: � V�J�'. J � <br /> � <br /> Phone�(day): - . <br /> Address: �>� �'�'�'� �" � �D c t�� City�����..�a�'�1�-ZfP� j�l��. <br /> Email andior Fax .�, n� <br /> Z� � <br /> PROJ�CT IN�ORM,�t,TlOt�; <br /> ' Type of Project: � � � <br /> Any earth movement rr,ay require <br /> ❑ Door(s) ❑ Remodel I ❑ �ire Camage MCWD review&permits: I <br /> Ninnehana Creek V1.'atershed District(MCW D} <br /> ❑ Re-roo?, aspNalt i (�Repair I ❑ Storm Damage 15202 Ninnetonka Blvd <br /> ❑ Re-roof, cecar � o A Deephaven, MN ��391 <br /> ❑ R„sto�aiion V��at„r Gamage <br /> � � Pnone: 952-471-Q590 <br /> ❑ Re-roof, other(speci"ry) � ❑ Siding ❑ Other: (specify) i �ax: 952-47"�-OoE2 <br /> I ❑Window(s) www.minnehahacreek.orq I <br /> Overall Froject DescripfiaR: v �, 9„ " � - <br /> =siirr,atecE Cor.s"truciion ��aivaiion o; Proiect (�xciuciing ;and) � � � ,?� <br /> �4P�LI�At�T �CFEi�JV1�L�Q^v�Mc�?i: <br /> � Agrees to provide all inrormatior required or requested by the Building Department; , <br /> • Ceriifies trat the informafion suppiied is irue and corre�t to the best or' nis/ner knowledge. The appficant recognizes tr�at they <br /> are soleiy responsible fa�submitiing a compiete appiicafion being aware that uoon �ailure to do so, the siaff has no alternative I, <br /> but to reje�t it until it is complete; <br /> i <br /> p Some or all of tne inTormatior that you are asked to provide on tnis appii�ation is ciassiTied by State iaw as eitner orivate or ; <br /> coniidenual. Private da;a is inrormation wnich pene;ally cannot be given to the pubfic but can be aiven to the suoiect of the � <br /> ; data. Conrideniia! da�2 is inrormafion whicn generaliy cannot be given to eitner the pubiic or tne subiect or tne cata. Gur <br /> i puroose and intended use of this inrormation is to annualiv updat� our re�ords and records o� other aovernmen;ai aaencies I <br /> reauired bv lati�. If vou refuse t0 SUDDIV tf12 IIl70fR18tI0R,tI12 2ppIIC8il0tl IT2\� no:be issued. <br /> Hppii�anf's Sigra'ture: <br /> Cat�: ��/6�j/�� <br /> Las:UQdateC: 0°•-d5-2D1" � � <br />