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���� �� ����c� <br /> , ����E�6il� E�'��'�i� �,��E�C���E)I� '��C ��6F�'�e�a€�c� � �er�e��at��� <br /> . (�nri€�aa�.��, �oa€-s, siair��, €��-rQof, ��c.} �- 2� z- <br /> Maiiing Aadress: I Permit numbsr. <br /> //=�v�,�- PO Box o6 I <br /> /�� �, �� Crysial Bay, MN 55323-OOri6 ' �ate:received: <br /> � , <br /> I�a �� �?P�-�' �, � Sfreet Address: Received by.: <br /> �~�'�, .k�'�'�y � � 2750 Kelie Parkwa <br /> ,'�^;��'��' ° Y Y Plan.reviewfee: <br /> �'�ESH�4� Orono, MN 55356 <br /> Main: 952-249-46Q0 Fax: �52-249-4010 www.ci.orono.mn.us II To:al �ee: <br /> This application rorm must be completeo in rull and all required information must be submitted. <br /> incompfete applicaiions will be returned. (Please print) <br /> u�N=RAL INFORMATIOn• <br /> Job Site Address: ��� 1 � <br /> Wil! this be a Parade ot Fiomes, Remodeiers Show.. se Home or oth Disp{ay Home? ❑ Yes o <br /> !f yes, a specia/event permit is required witn Poiice Department and City Council appro !60 days prior to the event. Shuttie bus servi e wil/be <br /> required unless appficant demonst;ates sufiicient or-site parking rs available. Non-permitted events will not be alrowed. <br /> CONTRACTOR!APPLICANT INrORMATl01�: <br /> fvame� '�'L, � � <br /> State License # �xpiration Qate: � � � — 1`]� <br /> Lead Ceriificafion Number: �xpiration Qate: <br /> (for work on homes fhat were constructed prior fo 1978 <br /> Phone: '� � —C.��� (offic�) (cell) <br /> Maifing Address: �1� Ciiy: � 1�.����ZIP: <br /> Contact Person: � �,� � � ppiicant is: Contractor / Hameowner �Gircle One) <br /> crr,ail and/or Fax: `2� �S ,� C4,�� , <br /> PROP�RTY OWN�R IN�ORMAT\IO\� <br /> N a m e: ���i1� C�� `�-'� <br /> Phone (day): -- �,3�^l—' `�.��o ' <br /> Address: ' '� �� l '� City:��'C�� ZIP: <br /> Email and/or rax <br /> PRaJcGT INFOrZMe�el'IOR: <br /> Type of Project: I Any earth movement rr�ay require <br /> ❑ Door(s) � ❑ Remodel ❑ �ire Camage � MCWD review&permits: <br /> I Ninnehana Creek Watershed District(MCWD) <br /> -roof, asphalt � ❑ Repair ❑ Storm Damage I <br /> 15202 Minnetonl;a Bfvd <br /> ❑ Re-roof, ce�ar I ❑ Restoration ❑Waier Gamage � Deephaven, Mh� 55391 <br /> Phone: 952-471-Q590 <br /> ❑ Re-roof, other(speci"ry) I� ❑ Siding ❑ Other. (soecify) Far.: 952-471-OoE2 <br /> ❑Window(s) I www.minnehahacreek.orq <br /> , <br /> Ove�all Froject Des;.ripfiaR: <br /> �sfirriatecE Construcfion Vafuatior, of Pro�ect (exciucfing �and) $ �'� � —�_ <br /> APPLI��►�T �CFrf�OWL�D��M�f�T: <br /> i � Agrees to provide all infiormaiion required or requested by tne Building Department <br /> • Certifies that the inTormafion suppiied is true and correct to the best of nis/ner knowledge. The appficant recognizes that tney <br /> are sofefy responsible for submitiing a compfete appiicaiion being aware that upon �ailure to do so, tne staff has no aliernative <br /> I but to reject it unfif it is complete; <br /> I, � Some or all o` the inTormation that vou are asked to provide on tnis appiication is ciassified b}� State iaw as eitne� privat� o� I <br /> confideniial. private da,a is inforrraiion wnicn generally cannot be qiven to the pubiic but can be glven to the suoiect of fhe <br /> � da�a. Confideniial data is informatior whicn gene;aliy cannot be given to �itner the pubiic or tne sub,iect or tne aata. Our <br /> � purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> reauired b� lav��. If vou reruse to suppfv the information,the aooii�a'tion mav noi be issued. <br /> Appfl�anf's Sigraiure: �, Dat�: � � <br /> � �l �� <br /> ��ast Update�: OF-6y-2D11 <br />