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���� �� ����c� <br /> • �e���e�e�� E�er�E� �.p��b�ca��a� ���- ���€��ar�a��� 6 �e�c������� <br /> (vvi�ao�.��, �iaa�-�, si�ing, �-�-raof, ��c.) <br /> / �� M,aiiipg Adaress: � Permit number. � � 2 " `�-� <br /> �\ , `� Bo>: oo I <br />� �� � � \ Crvstal Bay, MN 5�323-DOoo Qate re.,eive�: �- --� �� <br /> ���_,P�. � <br /> ��\� �tt�h�.� ti ; Street Address: I Receivea by: <br /> �� "� � 2750 Kelle�Parkwa <br /> t'"�`i��k� o� ) Y � Plan;r�vi�w f� . <br /> `�.r�E�sH�� Orono, MN 55356 I <br /> Mair,: 952-249-4000 �ax: 9:;2-249-4e10 ww�v.ci.orono.mn.us To:al Fee: ' / _ (�. � �( <br /> �P 7 0 <br /> This appficafion r"orm must be compl�ted in full and all required informafion must be submitted. <br /> fncompfete appficaiions will be returnec�. (Ptease print) <br /> ��t��RA� INrORIUlATIOn: ���� � .> 7 <br /> Job 5ite Address: ' -� G:�Y C�! <br /> Will t�is be a Parade of Homes, Remode��:rs Showcase Home or ot er Disp{ay �iome? I I Yes o <br /> !f yes, a special evenf permrf is required with Poiice Departmenf and Crty Council approval 60 cays prior to the event. Snuftle bus service will be <br /> required unless appiicanf demonsirates sufircient on-site par'Kmg rs available. Non-permrtted events wil!not be allowed. <br /> CONTRAC�OR!APPL CANT INF�RMATIOR': <br /> fvame: - � vY� ��l��d o <br /> State License # s� Expiraiion Qate: C� <br /> Lead Certir"ication Number: - Expiration Qate: l 1 /w <br /> . �_ Z F` - l'� <br /> (ror work on homes that were constructed prior fo 1978 <br /> Phone: �(P�j � �� G -�:�� �7 (office) �/ Z ' � 9 ' ,���� (cell} <br /> �aiiinc, ,�:ddress: `�o-� '�� YLGL,-9 .,�-,� .� �ity: �,g�J/� 6��,.� ZIP: �� c�' <br /> � <br /> Contact Person: ���� � tippiicant is: _ rac o / Homeowner �Girofe One) <br /> Errail and/or Fax: <br /> PROP�R i Y OWNER WF MATIO�i: <br /> Name: �, �� _ <br /> Phone (day): G�'�Z- � � �� � � <br /> Address: / 7 <br /> _ � �-'.�� ��i�c f� �� CitY� G/"�v� � ZfP' ��5���/ <br /> Email and/or Fax - <br />� PR�?J�CT IN�O?M�t,TIOR�: <br /> iType of Project: � � i Any eartn movement rray require <br /> ❑ Door(s) � ��model j ❑ Fire Qamage � MCWD review&permits: I <br /> � � Ninnehaha Creek Watershetl Gisirict(MCWD) <br /> ❑ Re-roof, aspk�alt ❑ Recair I ❑ Storm Dama e � o <br /> 9 I 1E202 Ninn..toni:a Blvd <br /> ❑ Re-roof, cedar ❑ Restoration I ❑Water Gamage ; Deeohaven, Mh 55391 ; <br /> � I j Phone: 952-471-Q590 <br /> ❑ R�-roaf, other(specify) j ❑ Siding the�: oecify) � Fa�c 952-471-Oo62 I <br /> � ❑Window(s) i I ww�n�.minnehahacreek.orQ i <br /> Ove�alf Fro�ec� �escnptiaR: <br /> �siimated Cor.struciion Vafuaiion o� Project (exciucfing ;and} $ � -?j, GG a <br /> �`iPPLI��i��" �.C��f�EUi/ULc�:�`M�P��': <br /> i � Agrees to provide all inrorma'tion required or reques'ted by the Buifding Department; <br /> I • `.er'tir'ies tnat the inrormaiion supplied is true and corroct to the best of his/ner knowledge. Tne applicant recognizes tna: they <br /> are sofeiy responsible for submit�ing a comoiete appiication beinq aware that upor �ailure to do so, tne siaff has nc alternaiive �, <br /> but to reject it unfil it is complete; � <br /> j i <br /> � Some o� all of tne inrormation that you are askec to provide on tnis appiication is cfassiTied by State iaw as eitner private or j <br /> ! confidential. Private data is inTormaiior, wni�n qenerally cannot be given to the pubiic but can be given to the subiect of the � <br /> da:a. Confideniial cata is inTormafion which generali� ;;annot be given to eitner the public or the subjec� o� tne oata. Our � <br /> I purpose and iniended use of this informafion is tc annually update our records and records of other qovernmen;al agencies j <br /> reauired b��law. If vou reruse to supofv, e n ormafior,,the ap fication mav no:be issued. ' <br /> � <br /> Appllcant's Sigrature: Cate: z� f Z <br /> �ast Uodated: DH-a5-2D11 � <br />