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� <br /> ���� �� ��'CU�E) <br /> . E������r�g Per�-nit A►pp�i�a�iQr� for (�Eai��e�a��e l RenQva�ia� �; `tZ4. <br /> • (winaov��s, doa�-s, sidin�, r�-rvof, e�c.) <br /> M,aiiing Address: , <br /> ,,;�`Q Permit number. <br /> PO Box 66 <br /> �c3� �� Crystal Bay, MN 55323-0066 Date received: <br /> , ,�,,� �i <br /> ��� 4�-;�� a, Sireet Address: :Received by: <br /> \`�' �"r ��'�' � 2750 Kelle P rkw <br /> \�t�v �'''4wG Orono, MN 55356 ay , Plan review fee: . <br /> 'kESH� <br /> Total Fee: <br /> Main: 952-249-4040 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This appfication form must be completed in full and all required inrormation must be sutimitted. <br /> fncompiete appfications wi(I be returnecl. (Please prrnt) <br /> G=N�RAL INFORMATI��: � <br /> . Job Site Address: � C � <br /> Will this be a Parade of Homes, Remodei�rs Showcase Home or other Display Home? ❑ Yes No !; <br /> If yes, a specia/event permif is required wrth Po(ice Department and City Council approva,�60 days prior to tne event. Shuttle bus service wil!be <br /> required unless applicanf demonstrates sufficient on-site parking is avai(able. Non-permitted events will not be allowed. <br /> CONTRACfOR/APPLICANT I FORMATIOf�: <br /> Name: /�CC�uJ ZZ C Lt � � `�� <br /> State License# ��"�� ��S Expiration Cate: <br /> Lead Cer�ificafion Number: �_(-, ���i_ � _.�j�� -1'� Expiration Qate: <br /> (for work on homes fhaf were constructed prior fo 1978 <br /> Phone: G 12 `� l (ofiice) (cell) <br /> Maifing Address: � �' �`Z � �'�- � W City: �. �.�� �ti1ZIP: 55 � � <br /> Contact Person: ��.� p S `� �e.,� �� Applicant is: ontractor / Homeowner (Gircle One� <br /> cmail andlor Fax: ��7� �7� ' ��c..,� <br /> PROPERTY OWNER INFORMATIC�t�: <br /> Name: �'j� ��J�� ��`��'� <br /> Phone(day): (U � � '71�� �'�6�' ° <br /> Address: ?.vG-��j� l�j\^c C�\ �� City: �i � C�i '�.1 C ZfP: .� � ,�j� 1 <br /> Email and/or Fax <br /> PRC}JE�T INFORM�t,�'I01�: <br /> Type of Project: 'I Any earth movement tray require <br /> ❑ D r(s) ❑ Remodel ❑ Fire Qamage ; MCWD review&permits: <br /> i Minnehaha Creek Watershed District(MCWD) <br /> e-roof, asphalt ❑ Repair i ❑ Storm Damage � 18202 Ninnetonka Bfvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Pnone: 952-471-0590 <br /> ❑ Re-roof other s eci A � <br /> , ( p fy) ❑ Siding ❑ Oth„r. (specify) � Fa>:: 952-471-Oo82 <br /> ❑Window(s) wwv��.minnehahacreek.orq <br /> - � <br /> Ove�all Project Description: <br /> �sfimated Construcfion Vaivafion or Project (excfuciing land) � ��j,�%�� " <br /> APP�I�AIVT ACKNOWLEDG�Mcf��: <br /> • Agrees to provide all informaiion required or requested by the Building Department; <br /> i <br /> • Certifies that the informafion supp(ied is true and correct to the best of his/ner knowledge. The app(icant recognizes that they <br /> are solely responsibfe for submitting a compfete appfica'cion being aware that upon failure to do so, the staff has no alternafive <br /> but to reject it unfif it is complete; <br /> • Some or all of the information that you are asked to provide on tnis appfication is cfassified by S,a'te law as eitner private or <br /> confideniiaL Private data is informaiion wnich generaliy cannot be given to the pubfic but can be given to tne subject of the <br /> � data. Confidenfial data is information which generalfy cannot be given to eitner the public or the subjec"t of tne data. Our <br /> purpose and intended use of this information is to annually update our records and records of other govemmen,al agencies <br /> reauired bv law. If ou reruse to sup fv the informafion,the anpfication mav not be issued, j <br /> _-�'_"„ ' <br /> AppficanYs Signature: �-yT-� ��--=� Qaie: ��r`6 � <br /> __._-� <br /> '_zst Updated: 0�-09-2011 <br />