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JUN-09-2011 02 :35 PM WALKER, ROOFING 6512510916 P. 01 <br /> ___ _...a . ,,. .,.,� „NN���Q���r� rv� �nternal Work <br /> � ' fwindows, doors, siding� re-toof, etc.) <br /> f4O"��= Mailing Address: <br /> .y-\ PO Box 66 Permlt number a�0 / � -�j(� <br /> ��0 Q\ Crystel Bey, MN 65323-0088 DeCe roceivad: � � <br /> �: 1 <br /> ^`::, � Strset Address: Recelved by; <br /> � 2750 Kell�y Parkway <br /> �+��s���', Orono, MN 85356 Plan review fee: <br /> Main; 962-249-4600 Fex; 852-24g.4g16 Totel Fee: ` �� , 1 � <br /> �[ww.ci,orono mn ��Q �t <br /> Thi�appliceticn form muat be completed in full and ail requlred information muet be�ubmitted. <br /> Incomplete appllcations wlll be returned, (Please print) <br /> QENERAL INFORMATION: <br /> Job Site Address: C� C N � Q <br /> WIII thia be a Perade of Homee, Remodelet^a Showcese Home or other Display Home� Yes <br /> N yas,a apac/el evenf permi!!s iequ/rod wiFh PoHc�e Department end City Councll eppmval BO da a � <br /> bquired unlesc appllCent demonsfr�qtee suBiclent on�slfe perkl�g it evallebla. Non pe�ittad events WlIltnot Be�e/owed. �w'll bB <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: ��,. � <br /> State License# o Expiration Dete; <br /> Lead Certiflcetion Number � -- �O ._p � I$Z Explr�tion Date: `� <br /> (for wor�on homos lhat wero con8tructed prlor tv 1878 <br /> Phone: 6 ( . (— I o (office) <br /> M�iling Address: (cell) <br /> 2 4 �a� c�ty: r. L zip: <br /> Contact Person; Applicent Is; / Homeowner iCircle One) <br /> Emeil and/or Fax: � �� . ,� � <br /> PROPERTY OWNER INFORMATION: <br /> Name: Q,, � �� , <br /> Phone (day): ig�, • y 7�r�19 � - <br /> Address� i��'� cyC�nrf1T p�.�c� c�ty� L�4� Zlp, <br /> Email�nd/or Fax � 3 �' <br /> PROJECT(NFORMATION: <br /> Type ei ProJect: Any eorth movomant mey roqulre <br /> ❑ Door(s) ❑Remodel � ❑Water pamege Mlnneh�he C eek Wetersh�d�D etrlct(MCWD) <br /> ❑Window(s) '�epair ❑ Starm DemaBe 16202 Mlnnetonka Blvd <br /> � <br /> ❑ Siding ��j R88toratlon ❑Other� (specify) ph na�v962-471 0580 <br /> �e-rvof ❑ Fire Oemage Fex: 952-471-0B62 <br /> www minneh�hacreek or� <br /> Overall Project Descrlpticn: o�� q�/�D /2,�,ef' b►F" Itov16 t C�qA,R�[r�E+ <br /> Eetlmated Conatructlon Valuation of ProJect(excludlne land) � gg�� Zq <br /> i <br /> APPLICANT ACKNOWLEDO�MENT: <br /> • Agree�to provlde all inFormatlon requlred or requeated by the Building Depertment; <br /> • Certlfles that the informetion supplled Is true end correct to the best of hls/her knowledge. The applicent recognlzes thet they <br /> ere solely reeponslble for submitting a complets appllcetlon beinp aware that upon fallure to do so, the staR has no alternative <br /> but to reject it until it ie complete; <br /> • Some or ell of the informaCion thet you are aaked to provide on this eppllcetlon is cleselfled by State law as elther private or <br /> confidential, Privete dete is information whlch generelly cennot be glven to the publlc but can be given to the subject of the <br /> data. Confidentlel d�te le Information whlch Qenerelly c�nnot be given to elther the public or the eubJect of the data, Our <br /> purpo�e and Intended use of thle InformeCion ia to annually updete our records and recorde of other governmentel egencies <br /> re uired b lew, If ou refuoe to Bu I the InPormetion the a lication ma not be Iseued, <br /> Applicant's Slgn�ture: Date; � � '� <br /> Lae!Uptleted: 03-01-2011 ��/� �A'�,L� �v.�j � f Tl� P�(,Fi �o � C�Qs�.l <br /> 7 <br /> 4-4�(un E rv`�{ �� SA�, <br />