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JUL—x9-2�11 09 :39 AM WALKER� ROOFING 6512510916 P. 01 <br /> —_. �...� . _. ..... ..N�,,�...�.�.v�� �v� ����v���ai vrV�R <br /> �windows, doors� siding, re,roof� etc.) <br /> Mallinp Address; Permit number: ���/�DO 7 <br /> �O��,�0 PO Box 66 <br /> Cry�tal Bey, MN 55323-0066 Det�reCeived: q l <br /> � <br /> �. <br /> � ''. � Strset Address: Recelved by; <br /> 2750 Kelley Parkway Plan rovl�w fee: <br /> �!r�__� <br /> Orono, MN 55358 <br /> �_ .� - Total Fee: ��Cv.�� <br /> Main; 852-24�-4B00 Fex: 962-24G-a618 www,ci.orQ.no.mn,us <br /> Thls application form must be completed in full snd all required Informptlon must be submitted. <br /> Incomplete applicetlons wlll be returned. (Flease print) <br /> GENERAL INFORMATION; <br /> Job Slte Address: �Jt 3 � �'(�NE�T <br /> WIII this be e parada of Homea, Romodelers Showca�e Home or other Dlaplay Home? Yes No <br /> ll y�s,a speclal event penril!la roqulred wlfh Pollce Depertment end Clty Councll epproval BO deya piror to the event. Shu!!le bua serv wlll be <br /> ►equired unless appllcant demonsfrate8 suli�clen�on-alte peridng 19 eVeilable, Ncn-pe/mitted evsnt8 wlll not be ellowed, <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name; W �� ,� (,�, <br /> State Llcense# t.�2'2'� Explratlon Date: � � <br /> Lead Certification Number: �- �- �5 q�, - �d _ v � � �Z Explration D�te; L.� � � <br /> (1or work on homea that were conatructed pNo►to 87B <br /> Phone: !�?� 651 -ZS� �o� �o (office) (ce��) <br /> Meiling Addrees: � Clty: 5 j'(�� „ ZIP: � �- � �,4 <br /> Contact Person: �flY �,(� Applicant is; / Homeowner tcircie on•1 <br /> Emeil and/or Fax; <br /> PROPERTY OWNER INFORMATION; <br /> Name: I�iQA��f 5T. �(it�R�`LF� <br /> Phone(dey); (P (Z-�o ��� !3Z <br /> Address: c?,4�� City: ZIP; <br /> Emei{end/or Fax '!' <br /> PROJECT INFORMATION: <br /> Type of ProJoct: Any earth movo�nent mey requlro <br /> ❑ Door(s) ❑ Remodel ❑Weter Demege MCWD revlew�pormits: <br /> Minneheha Creek Wata►�hed Dlstrlct(MCWD) <br /> ❑Window(�) �,tepeir ❑Storm Damage 19202 Mlnnetonka Blvd <br /> � Siding ❑ Restoration Q Other (specify) Deephaven, MN 56391 <br /> Phone; A62-471-0590 <br /> �ie-�oof ❑ Fire Dsmage Fax: 952�71-0862 <br /> www,m Inneh ahacreek.ora <br /> Overall Pro ect D�acrlptlon; a '� o -- �, p/o� <br /> Estlmated Conatructlon Veluatlon f ProJect excludln land � � � , �� <br /> APPLICANT ACKNOWLEDGEM NT: <br /> • Agrees Co provide all inform8tlon requlred or requeated by the Building Depertment; <br /> • Certlfie�thet the information eu plied la true end correct to the best of his/her knowledOe, The eppllcant recopnizes that they <br /> ere solely responsible for aubml Ing a complete appliption being awere that upon feilure to do so, the steff hea no alternaUve <br /> but to reJect It unCll It la complete <br /> • Some or ell of the informatlon et you �re askad to provide on this applicetlon Is cl�ssified by State law as either prlvate or <br /> Confidential, Prlvete dete is inf rmation whlch qenerelly csnnot be glven to the publlc but can be given to the subject oP rhe <br /> date. Confldentlal data Is Infor etion whlch generelly cannot be given to elther the public or the �ubJect of the dete. Our <br /> purpo�e and intended use of th e Infarmation le to ennually update our records and recorde of other governmentel agencies <br /> re uired b lew, If ou refuse to I he Information the e Ilcatlon ma not be imaued. <br /> Appllcant's Sipneture; Date; � � � <br /> Last Updated; 03-01•2011 <br />