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� a ���� �� Q��-��c� yr.�� <br /> �������� E�e���� �,����e���c�€� ���- ����e�r��r��� / �ar�c������� <br /> �UIP6�lC�OM.°�, E�OUC�., SiE�ICI�, �'�-E'Ce�f, �rC.� <br /> M,ailrng Aaaress Permit number: o�� /�-0 <l �J <br /> �i��,� PO Box o6 <br />� /(� (��� Crystal Bay, MN 55�23-0�06 Date received: //- ��� � <br /> i � � h>,°y_ i <br /> ��,� �14 4�� � ! S'rreei Adaress: I Receiv�d by., � -� <br /> \��^��ry,,�,, ��/ 2750 Keliey Parkway I Plan review.fe <br /> ���.t� ����Y.� Orono, MN 55356 � � � <br /> ESHo � <br /> Total;r=e�: ;�7 3. (�� <br /> Main: �52-245-4000 Fax: 952-249-4010 www.�i.orono.mn.us <br /> Tnis appfication r"orm must be compl�ted in rull and all reauired informafion must be submitted. <br /> fncompfete appiicaiions will be returnec4. (P/ease prrnt) <br /> v��I�P.A� INFORMl�TIO►�: , � <br /> Job Site Address: �� � �;� �� �U,�CU ' <br /> Wiil ti�is be a Pa�ade of Homes, Remocfeiers Showcase Fiome or other isplay Fiome? ❑ Yes � P�o <br /> !f yes, a special event permit is required wifh Po(ice Depanmenf and City Council approval 60 days prior to fhe even±. Snuttie bus servrce wil!be <br /> required unless app(i;,ant demonstrates suffrcient or-site parlcing rs available. Non-permitPed events will not be aliowed. <br /> CONTRACTOR/APPLICANT INrOP,MATI f�: <br /> Name: nr �,�J\ . �� <br /> State License # �,��I � �c /• l�(�j�->� Expiraiion Cate: <br /> Lead Certir"icafion Number: �� �xpiration Date: <br /> (ror work on homes that were construcfed prior io ?978 <br /> Pnone: �� _ �(�V (office) (ceil} <br /> Maiiing Addres : - (' ��� � ` City: , - �;��, ZiP; �"-�� <br /> Contact Person: n I A u�ant is: Contractor / Homeowner � <br /> �J� �f�C�,lN1�i c�.�s PP�" (�irde One� <br /> �mai! andior Fax: <br /> PROP�RTY OWNER INFOr2Ml�,TIO►�f: <br /> Name: �1�(� �- �,����. ����1 <br /> Phone(day): - <br />� Address: l�[nLl� ��i� �U City: f" �(� ZfP: <br /> Email and/or =ax <br /> �R�.���� s�v�-o�nn��ion: <br /> Type of Project: I, <br /> � I Any earth movement m�ay require <br /> i MCWD review&permits: ! <br /> ❑ D or(s) � ❑ Remooel i ❑ Fire Qamage Ninnehana Creel:Waiershed District(MCWD) <br /> .. e-roof, asph i ❑ Repair I ❑ Storm Damage I' <br />� 1E2G2 Ninnetonica Blvd <br /> i Re-roof, ceuar ! ❑V�at.,r Damage Deeohaven, MN 55391 <br /> ❑ Restoration I � A I <br /> Phone: 952-471-Q590 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other. (sqecify) ��� �a>: 952-47i-On82 <br /> ❑Window(s) j www.minnehahacreek.orq I <br /> � � i <br /> Ove�all Froject Descripiiar,: �J_� � - <br /> =siirrateeE Cor�s"truciion �°afuarior. oL Project (exciucfina �and) � r� �� <br /> � <br /> APPLI^l�I�T �.�FCi�EUV19L�D;�����T: <br /> I � Agrees tc provide all inrormation required o�reques'ted by the Buifding Department; j <br /> I • �eriifies trat tne inTormafion suppiied is true and correci to tne best or' nis/ner icnowiedge. Tne appiicant recognizes tna� tney I� <br /> are soleiy resoonsible for submitfing a compfe'te appiication being aware that upon failure to do so, the siaff has no aliernarive I <br />� but to rejec't it unfil it is compiete; i <br /> ie Some or al� of the informatior that you are askea to provide on tnis appiication is cassiTied 'by State iaw as eitn�r privat� or <br /> i conr'identia;. ?rivate da;a is inTormation wnicn generalfy cannot be given to the public but can be given to the subiect of the i <br /> ! aa�a. Conrideniial data is information which qene,aliy cannot b� giver to eitner the pubfic or tne sub,iect or tne aata. Our <br /> li purpose and intended use of this informaiion is tc annuall�� updat� our records anc re�ords or' otner govemmental aaencies <br /> reauired bv law. If vou reruse tc supaiv tne information. tne ao fi�atior mav no�be issue�. <br /> /',ppii�an{'s Siqraiur�: ��7 naL�: l�—� —/� <br /> Las;UoGateC: 0�-0�-2C1"�� <br />