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JUL-14-2011 02 :42 PM WALKER, ROOFING 6512510916 P. 01 <br /> ��...�...� . �...... . .rr■.v�w.■v.■ .v■ ..��v� �Iw� •�v� n <br /> � <br /> (windows� doors, sldln , re-roof, etc.) <br /> Meiling Address; Permit number, o?O//^�Q�o$ <br /> . O¢0,j�O PO Box 68 <br /> Crystel Bey, MN 55323-0066 Date received; 7- 1<S- I � <br /> � ��';, �, Streat Addrsea' Reoelved by; <br /> �, 2760 Kelley Parkw�y Plen revlew fee: <br /> '�� e o��� Orono, MN 55356 <br /> � _-`-• 7otel Fee; /�0 5 8 / <br /> Maln: 952•249-4600 Fax; 852-Z49-4616 www.cl,orono.mn.�,$ • <br /> This appllcatlon form must be completed in full�nd eli requirod informatlon muet be submitted, <br /> Incomplete applicetlons wlll be returned. (Please print) ✓�s� <br /> GENERAL INFORMATION: r1 �{8'OZ I 3Z�F 31�t 3 `�Z-� l <br /> Job Site Address: [, �O ( ��Y�SN�� ��. <br /> WIII thle be a Parade of Homee, Remodeivrs$howcase Home or other Display Mome9 Yes No �/�3 <br /> I1 yea,a speclel evenr parm�f ie roqul►ed wfth Pollco DepaRment end Clty Councll approvel QO days pNor to the event, Shuttle bus ssrvke wlll be <br /> requlrod unleas eppllcenf demonatrales suMc/ent on-sitv perkiny Is aveilpble. Non-permlhed evenfs will not be ellowed, 55i/c.{ <br /> CONTRACTOR/APPLICANT INFORMATION: ��'� <br /> Name: � N <br /> State License# t.��� Expiretion Date; '3� � <br /> Lead Certific�tion Numb�r: �,-�' - g �q� _ �p - p 5 �� Expiratlon Date: <br /> (Mr work on homos t�at we�constructod prlor to 1978 <br /> Phone: � �� �� B 1 I - �Iq � (office� (cell) <br /> Meiling Addreas: P Clty: L ZIP; ( <br /> Cont�ct Person: �^,�.� Appllcent Is; recto I Homeowner �ci►cis o�•� <br /> Emeil�nd/or Fex: <br /> PROPERTY OWN�R INFORMATION: <br /> Name: M 1 K� �A'L.� <br /> Phone (day); q����3- 3� I'I <br /> Addre�s' 2F � ��c��r �4. Gty: LbhKst Ii� Z1P� 5S� S� <br /> Email andlor Fax <br /> PROJECT INFORMATION: <br /> Type of proJect: Any earth movement may requlre <br /> ❑ Door(s) ❑ Remodel ❑Water Damape MCWD review 8 permits: <br /> Mlnnehah�Creek W�tershed Dl�trlct(MCWD) <br /> ❑Window(s) (�Repeir ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Siding ❑ Restoretivn ❑ Other (specify) Deepheven, MN 55381 <br /> Phone: 962-471-0690 <br /> �e-roof 0 Fire Demege Fex; 852-471-0682 <br /> www,,�tli��h�hacreek.ora <br /> Overall Pro ec! Descrl tlon: 0 � o D ��-�,,��;� <br /> Eatlmated Constructlon Valuetlon of p�oJe�t(excludln� land) $ -T����j , �� � ��,_� <br /> APPUCANT ACKNOWLEDOEMENT; I.�,I , <br /> . Agrees to provide all Info�metion requlred or requeated by the Building Depertment; � <br /> �I +� <br /> . CeRlfles thet the Informatlon supplled Ig true and correct to the best of his/her knowledge, The appllc�ril,r�ecognizes that they <br /> are solely responsible for submittinQ a complete appllcatlon being �were that upon fallure to do so, the�teGf has no al�ernative <br /> but to re�ect�t unt���t�s comp�ete; ; � <br /> . Some or ell of the Information that you are asked to p�ovlde on this epplicatlon le cleeeltied by Stete i&aiv i�s elther privata or <br /> confldential, Private deta la Information whlch generally cannot be glven to the public but can be giv�m�tb the eubJect of the <br /> dete, Confldentlel dete is intormetlon whlch generelly cannot be given to either the public or the eub�bdt of the deta. Our <br /> purpose end intended uee of this Information is to ennuelly updete our recorde end recorda of other;ytiv�rnmentel agancles <br /> ra uirod b lew, If ou refuae to�u I t e Inform8tion the a lication ma not be issued, � � <br /> Applicant'a Slgnature: Date: i{� <br /> Last Updated: 03-01-2011 I <br />