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OC•3'-07-2011 02 :35 PM WALKER, ROOFING 6512510916 P. 01
<br /> _r..._....a . _...... . .r�,......�....... .... ..�..��.�v�.�.�ivv � ��ai�v�a��v��
<br /> (windows, doors, siding, re-roof, etc.)
<br /> �.�:==—�„ Melling Address; Permit number: 02 U//--��a-/ 5l
<br /> /O�O,�.O PO Boz�6
<br /> Crystal Bey, MN 55323-0086 Date received; !�- 7-!/
<br /> I Sf�etAddress,- Recelved by: �
<br /> � �.,,.;�'�. �
<br /> 27b0 Kelley Parkway
<br /> � �.�; Orono, MN 55356 Plan roview fee:
<br /> -.- .--:=:.- Tota�Pee: 3(0�j�, D �J
<br /> Meln: 962-249-a600 �ax; 852-249-4616 �prvy,c',Qrnno,mn,.�,,a
<br /> Thic�pplication form must be complet�d in full and all required information must be submitted.
<br /> Incvmplete applicetlons wlll be returned. (Pleese print)
<br /> GENERAL INFORMATION;
<br /> Job Slte Address; C � P(�
<br /> WIII thls be a P�rede of Nomes, Remodelers Showcase Horne cr other Dlaplay Home? Yea No
<br /> ll yos, e speclel ewn�pennn IS►equlred wilh Pollce DepeRment end Clry Councll epprove/60 daya prfor to the evenk Shuttb bua service wlll be
<br /> requlrod unleee Applfcent demonatrat�es 9ulliCianf on�alte p�9lklnp Js avdileble. Non-pe►mlttod events wlll nof be alloWed,
<br /> CONTRACTOR I APPLICANT INFOaMATION:
<br /> Name: _�RG,1�?�fyo h'��1�q..� '
<br /> State Licen�e# 1,��2,q Expiration Date; `3 � (
<br /> Lead Csrtification Number � ., N F!T- I ((� �02� � Expiration Date; �
<br /> (for work on homea thet were constwot�ed pHor to 1978
<br /> Phone: , . (office) ��� .- � 5 (� p q (� (cell)
<br /> Mailino Address: 21.'1_C). G,4PP �p� Clty: (S T. PA-I.��- ZIP; y
<br /> Contact Pereon: �(J►r �� Applicant ie: ont a / Homeowner �a��i.o�•�
<br /> Emall andlor Fax: q��5 wA fL� � , ,�.�
<br /> PROPERTY OWNER(NFORMATION;
<br /> Name: OFl�V�E S 1f�7�NFS'S`�
<br /> Phone (day): ( 2�-'7 ,p - 4�� S
<br /> Address; ,a,��]` P(,,4-�,E GtY: Ld�/!,r �At�cg ZIP: �S '� s�o
<br /> Emeil end/o�F�x
<br /> PROJECT INFORMATION:
<br /> Type of Pro�set: A�y earth movemant may roquiro
<br /> ❑Door(s) ❑ Remode) ❑ Fire Damage MCWD revlew 8 permlto;
<br /> Mlnnehehe Creek Watershed District(MCWD)
<br /> e-roof,asphalt ❑ Repalr ❑Storm Demage 1H2O2 Mlnnetonk� Blvd
<br /> � Re-rocf,cedar ❑ Restoratlon ❑WaCer Damage Deephgven, MN 55391
<br /> Phone; 852-471-0580
<br /> ❑ Re-raof,other(sp�clfy) ❑Siding ❑ Other: (speCify) Fex; 952-471-0682
<br /> ❑Wlndow(8) www,minnehahecreek ol'�
<br /> Overall Project Deac�lptlon: (Z.�,� ,�� r/.�E �,�fqu5�� C��,@,.�1�„�.t 5�le'Q
<br /> Estlmated Constructlon Valuatlon of ProJect(axcluding land) S 'Lp p�7 , Z-Z
<br /> APPLICANT ACKNOWLEDGEM�NT:
<br /> • Agrees to provide all informetlon required or requested by the Building Depertment;
<br /> • Ce�lfiea thet the Information supplled Is true end correct Co the best ot his/her knowladge, The eppllcent recognizes that they
<br /> are solely responsible for aubmittin9 a complete application being ewero thet upon fsllure to do so, the st�ff hes no elternative
<br /> but to reJect It untll It Is complete;
<br /> • Some or ell of the Informetion thet you are eeked to provide on this application is cles�lfled by State law as either privete or
<br /> confidentiel, Privete data la Informetion which generally cennot be given to the public but can be givan ta the subJeCt of the
<br /> deta. Confldentlel deta is informetlon which gener�lly cennot be glven to either the public or the subJect of the date. Our
<br /> purpoae and intended use of this informaton is to annually updata ou� �ecorde �nd records of other aovernmentel �gencies
<br /> re uired b lew. If ou refuee to I th nfo etl n, the e Ilcetlon me not be iseued,
<br /> Applicent's Sipneture; Dete: [ Q
<br /> Last Updated: 09-09-2011 ���G C�Ll-- `�r` ��5� � �
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