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���� �� ����� <br /> � �������� E�e���� �,��r������c�� ��€- �������a�c� � �er�c��a���� <br /> (�i�a��.p�, �oa€-s, siair��, �-�-ra�f, ��c.} <br /> /�� Naiirng Adaress: Permi't numb�r: <br /> %i'�v .� � PO Box oo � � � <br /> �� � �py �\\ Crystai Eay, MN 55323-0�66 i Qate received: <br /> �� <br />� I�.a � � �� a.�� SireetAddress: I`Received by. <br /> `\� , �'�'� �� 2750 Kelley Parkway <br /> L�� �. � Pfan:reviewfee: <br /> ` -�.rrEs�o4w� Orono, MN 55356 <br /> Mair,: �52-249-4000 �ax: 952-249-4010 �,nnr�,,.� . Total Fee: <br /> i orono.mn.us <br /> This application rorm must be comqleteo in rull and all required informaiion mus; be submitted. <br /> fncompfete appficaiions wil( be returner�. (Please print) <br /> u�.t�`r2AL INFORM,�4TIOR: <br /> Job Site Address: p � S W 3 � .�j �-- ����� <br /> Wiil this be a Parade oT Fiomes, Remodefers Snowcase Home or other Dispfay Fiome? ❑ 1'es ' �io <br /> If yes, a special event permit is required with Pofice Depanmenf and City�ounci(aoprova!60 cays prior to tne event. Snuttte bus service wil/be <br /> required unless applicant aemonsrrates sufiicienf or-site par'rcing is available. Non-oermrtfed evenrs wil/not be alrowed. <br /> CONTRAC�'OR!a.PPLICANT INrOP,MATIOIt'.: <br /> fv a m e: ���J �L-'9 v i}�.I�'G�'r <br /> State Licer,se � �xpiration Qate: <br /> Lead Certificafion Number: Expiration Qate: <br /> (for work on homes fhat were construcfec'prinr io 1978 <br /> Phone: �'j S a - �-�-`7 I - �i 1 Lv � ioft��P) Co < � - Lv (�i - /d (..o a �����> <br /> Naiiing Address: �?o � �, G/�S �:a �D� ; .� j ►2f��i� City: p.�2ar-�:.� Zlp js��i � <br /> Contact Person: �J N �L�}�-�..,�-c�(-f- Appiicant is: Contractor r' Homeowner (Gircle Une) <br /> Email and/ar Fax: � �L�}�/ Cw, � � Its i < <��� <br /> PROP�R i Y OWN�R I � RMAfIOI�: <br /> N a m e: .�--, �-'fi�-�1-(,.�,1 <br /> Phone(day): �v t a- L,v c �`t 1 a Lo � � <br /> Address: �::, 'S -�, CJ}�5 c� Q� , .� � 20 Ciiy� �/�:�v.� � ZIP� S�S �"z � <br /> Email and/or Fax � t4 J � ���t S � , L.-. � <br /> PR�,l�CT IN��RM�t,TIOR: <br /> Type of Project: � <br /> � i Any earth movement rr�a�r require <br /> ❑ Door(s) I, ❑ Remodel I ❑ Fire Qarnaqe � MCWD review &permits: <br /> I ` I Ninnehana Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt � ❑ Repair ❑ Storm Damage � 1 E202 Ninnetonka Bivd <br /> � <br /> ❑ Re-roof, cecar � ❑ Restoration � ❑V�,'aier Camage �I Deepraven, MN 55391 � <br /> I ! i Pnone: 952-471-Q590 I <br /> ❑ Re-roof, other(speci'ry) '� �Siding � ❑ Other. (soecify) I Fa;; 952-47i-0o82 <br /> ��� e��L I �-Window( �„ �7�C /d c��c-� j www.minnehahacreek orq <br /> � <br /> �ve;all Projec� DescriqiioR: <br /> =siirr,ated Cor.s"trucfion Vaivaiior of �ro�ect (Ax^fu�iing �and) � � �� (; S� � <br /> � <br /> r4�'PLI�;�I�T �^k'oi�011�►!�E?��fVV=P�i: <br /> � Agrees to provide all informafion required or requested by the Buifding Department; <br /> i <br /> • :;ertiTies tnat the inTorrr�afion suppiied is true and corre�t to the best of his/her knowledg�. Tne appficant recogniz�s tha: tney � <br /> are sofely responsible for submitting a compiete appiicaiion beinq aware that upor failure to do so, tne staff has no alternaiive � <br /> but to reject it unfil it is compleie; <br /> I <br /> � � Some or all of tne iniormafior tr�at you are asked to provide on tnis aopGcation is ciassified b�� Staie iaw as eitner privat� or I <br /> � �onfideniial. Private da;a is information wnicn gene;aliy cannot be piven to the pubiic but can be given to the subiect of the I <br /> , da�a. Conridentia! dai2 is information wnicn qene�aliy cannot b� given io eitner thF pubiic or tne subiect o` tne data. Gur j <br />� j ourpose and intended use of this inTormation is to annualfy update our recores anc records o� otner povernmen;al agencies � <br /> j fEQUlf�d bV�BV�� �i yOIJ f�TLIS�t0 SUpDIV ttl2 IfliOffl'i8TI0R thE BDp�I"BTIOC� IT8\� f10I DA ISSU"d j <br /> ,� <br /> AppiicanYs Signaiure: '� �r - Caie: l� "��-��} <br /> Last Uodatea: D�-dS-20^1 <br />