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� <br /> �t�� €�f �E"E��C� ,. <br /> ���i�gr�� F������ �,�������Q�c� ��€� �����ar�ac��� f €�zn�c������� . -t� <br /> (vvi�aav�p�, �ioa€-�, �iciir�C, ��-rQof, ��c.} � (� . �t( <br /> Naiirng Adaress: <br /> ��� I Permitnnumber. <br /> %�w ��� PO 5ox 60 � � <br /> /� � ���� Crysial Bay, MN 55323-OOo6 i Cate received: <br /> 3 � <br /> �,a �� :;`-.r i ��,Receivetl o � <br /> �, �E„� �. StreetAddress: Y <br /> ���� � � "'`ro �ti� 2750 Kelley Parkway I � . <br /> ��;�,� P�an:review ree: <br /> ���`��=Esxo4` Orono, MN 55356 : � <br /> i Total;Fee: <br /> Main: �52-249-4000 Fax: �52-249-4010 www.�i.orono.rnn.us <br /> This appfication form must be completea in full and all required information must be submitted. <br /> incompfete appficaiion,�s will be returned. (Please print) <br /> ���l�RAL INFORM�,TIOt�: l y��/'�; ✓��-�� � � � f� t'� � �� � <br /> Job Site Address: �� <br /> Will tt�is be a Parade mf Homes, Remode�ers Snowcase Home or other Uisplay Fiome? � � Yes No <br /> lfyes, a specia/event permit is required wifh Po(ice Deparrment and City Council approval 6G days prror to the event. Snutfie bus servrce will be <br /> required unless appiranf demonstrates sufficienf on-site parking rs avarlable. Non-permrtted events will nof be allowed. <br /> CONTRAC�OR!APPLICANT INFOP,MATIOR: <br /> Name: ��S �x�e.-, v�rs <br /> State License # Q G (� � � S -7 �xpiraiion Cate: 3- 3 i,.�/� <br /> Lead Certirication Number: Expiration Date: <br /> (Tor work on f►omes ff�at were constructed prior io 1978 <br /> Phone: �� �- �>�. �c;�� (ofrice o <br /> i ) � ��— � J�G -3o 7 (c,.lf) <br /> Maifing Address: ; ,U u ��,- �c.v, City: ZIP: �' �� 3 S) <br /> Con,act Person: ��r� �� � � �s ,�pplicant is: ontractor Homeowner (Circle One� <br /> Email andlor Fa>:: �`�,t-S ��fe�- �b.rt � ��r � / ��G i�.—� <br /> PROPcRTY OWN�R INFORMATIOt�: <br /> Name: <br /> Phone(day): . <br /> Address: <br /> City: ZIP: <br /> Email and/or �ar, <br /> PRC�J�GT IN��RM�t,�'IO�: <br /> Type of Project: ! I � Any eartn movement rray require <br /> ❑ Door(s) �' ❑ Remodel ❑ Fire Damage �� MCWD review&permits: I <br /> Ninnehana Creek UVatersned Gistrict(MCWD) <br /> �j Re-roof, asphalt ❑ Repair i � Storm Damage i 1 E202 Ninneioni:a Bivo <br /> �te-roof, ceaar ❑ Restoraiion ❑Waier Gamage �Peoraven, MN 55391 <br /> i Phone: 952-471-Q590 <br /> ❑ Re-roof, other(speci"ry) ❑ Siding ❑ Other: (spec'rfy) I r=a>;: 952-471-Oo82 � <br /> i ❑Window(s) � � www.minnehahacreek.orQ � <br /> Ove;all Froject �es�ripiior,: <br /> �siirriatecf Cor.sirucEion �'aivaiion of Project (exciucfing fand} � -,�-r�' c �� °' <br /> i� <br /> AAp�.���`i�� ��.F���D�R CQ s����!I: <br /> � Agrees to provid� ali inrorma'tion reauired or requested by fne Buifoing Depar[ment <br /> I � �eriiries trat the inTormation supplied is true and corro�t to tne best or' nis/ner knowledge. The applicant recognizes tha; tney � <br /> are solefy responsible for submitiing a �omplete appii�aiion oeinq aware trat upon failure to do so, tne s�aff has nc afternaiive I <br /> ' but io reject it unfil i;is compiete; � <br /> � Some or aL o`tne inTormafion that you are askec to provide on tnis aopiication is ciassiTied b}� State iaw as eiYner privat� or '', <br /> coniideniial. ?rivate data is informaiion wnich qene;ali�� cannot be given to the public but can be qiven to the subiect of tne ; <br /> , da:a. ConTideniia! data is information wnicn qene�aliy cannot be given to eifner the pubii� or tnG subiec't o` tne cata. Our <br /> purpose anc iniended us� of this inTormaiion is tc annuali�� update our recores and re�ords of otner qovemmen;a� agencies � <br /> reauireCl b�� lav��. 1=vou refuse t0 S Dly fCl� If1TOffitaTl , t BDpIIC3T10(1 fT12�� f10i b� ISSU�C. I <br /> �1QC�II:?.fl`.'S SlQtiaLUfP: �"��' C�.�_� �� ' ( Gj- �� <br /> - �i2i�: <br /> �zst Updated: D��-D9-20 i^ <br />