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. ���� �af C��-a r�� <br /> , � ��6��ing Perrnit Appii�a�iQr� �or NEair��e�ance / F�e�Qv��io� <br /> (winaov��s, dvors, siding, r�-roof, etc.) <br /> M,aiiing Address: ' �Q/�—(�� <br /> �—� ' Permit number: <br /> ,�'�,.^w Q,�. � PO Box 6o I <br /> �� ��� Crystal Bay, MN 55323-Q066 j Qate received: ��a / <br /> � <br /> �'�a 4 ' �' �, i Street Address: Received by: <br /> ��} <br /> ���'�c, ; �; � G�/ 2750 Kelley Parkway Plan review fee: <br /> '\t`�,kEs��`,� Orono, MN 55356 �j <br /> Total Fee: o�C3.'�� <br /> Main: 952-249-4000 Fax: 952-249-4016 www.ci.orono.mn.us <br /> This appficaiion rorm must be completed in full and all required int"ormation must be submitted. <br /> fncompiete appficaiions will be returnecl. (Please print) <br /> GEN�RAL INFORMATIOt�� ��� �r S�fi� 7 � � �`�v7 � ��� �s `7 ��1 <br /> Job Site Address: � <br /> Will this be a Parade of Homes, Remodeiers wcase Home or other Display Home? U Yes No <br /> !f yes, a specra!event permit is required with Police Depanmenf and City Council approval 60 days prior to the event. Shuttie bus ervice wil!be <br /> required unless applicant demonstrates sufricient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLI��Nr"�ORMATIONf: <br /> Name: � f-} � " �' \ � o r l��'� ��- r`a � ����- <br /> State License # Expiration Qate: <br /> Lead Certification Number: Expiration Qate: <br /> (for work on homes fhat were constructed prior to 1978 <br /> Phone: (ofiice) (cell) <br /> Maiiing Address: Ciiy: ZIP: <br /> Contact Person: ��� �� i3� r�� �-ti � �� `� Appficant is: Contractor / Homeowner (Circfe One) <br /> E,rt-�ail an�,�-- ��cz� �� ,2�7 _ �� `7 � <br /> PROPcRTY OWN� INFO ATIO�t: '.I <br /> �ame: �� � �` �'l � ������ u <br /> Phone (day): � �( � 3 � � ( Z, � �� <br /> Address: � Z.. �I �C �O�E�l. �v�- .� City;L•�uG'i^ C9'�� ZtP: � S p'�-� <br /> Email and/or Fax <br /> PR�JECT INFORM�TIOI�: <br /> Type of Project I /any earth movement rray require <br /> ( ) emodel MCWD review& ermits: <br /> I ❑ Door s ❑ Fire Camage � P <br /> i Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 1E202 Minnetonka Blvd <br /> ❑ Re-roof, cedar I ❑ Restoration + � Deephaven, MN 55391 <br /> ❑V�,ater Damage I Pnone: 952-471-Q59� <br /> ❑ Re-roof, other(specify) I ❑ Siding ❑ Other: (specify} j Fax: 952-471-0682 <br /> i ❑Window(s) ; www.minnehahacreek.orq <br /> Ove�all Project DescriptioR: <br /> �sfimated Construction Vafuafion o� Project (exciuciing iand) � - <br /> APPLICAI�T ACKNOWLED��M�Iv�: <br /> • Agrees to provide all informaiion reauired or requested by the Building Depariment; <br /> • Certifies tnat the information supplied is true and correct to the best of his/her knowledge. The appii�ant recognizes that they � <br /> are solefy responsible for submitting a complete appiicaiion being aware that upon failure to do so, the siaff has no alternaiive <br /> � but to reject it until if is complete; <br /> • Some or all of tne inrormation that you are asked to provide on this application is classified by State law as eitner priva'te or I; <br /> �� confideniial. Private data is inforrrzation wnich qene�aliy cannot be given to the pubfic but can be given to the subject of fhe I <br /> i da.a. Confidential daia is informatior which generally cannot be given to eitner the pubiic or the subject of tne data. Our � <br /> I purpose and intended use of this informafion is to annualfy upc3ate our records and records of other govemmen;al agencies � <br /> re uired bv law. If ou rer to suppfv the inrormafion,the aopfi�ation mav not be issu�d. i <br /> A licant's Si nature: � �- - l. <br /> PP 9 � � Da'te: �d�� Z �, � Z. <br /> _ast Updated: OP-09-2D1' <br />