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��6/3�/2016 14:25 952-935-9544 MN RUSCD PAGE 02/02
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<br /> B�aa�d�ng P�rmit Apppdca�ion fiar 11l��int�a���a�� ! R�pia�emer�� 1 Remodei -� �iesRde�t'sa� Q��,Y
<br /> Qe.�. qn�ieadawr��, c��,ors, sad���c�, r^-��ca�'. ^dc. -- �d� ��"�;�.6�TUE��L, ���l�.k��9��E)
<br /> �� �_� Mailin.q Addr'ess; Rermit number, ���/ `�
<br /> �V PD Box 66
<br /> Crystal Bay, MN 55323-0066 Dato received: �
<br /> Str�Qt Address; Recefved by:
<br /> �F ! � � ; 275D Kelley Parkw�y Pian review fee:
<br /> r,� , �,�' Orono, NfN 5535G
<br /> �rR r,511 C>'�
<br /> 'tOtal Fee: I
<br /> � Main, 952-249-46o0 Fax: 952-249-4616 ww�nr.ci.orono,mn.4� Q�1 �
<br /> This application form must be campieted in fulf and all required information must be submitted.
<br /> incomplete applic�ations�nrili be returned. (F�Ieaso print)
<br /> G�N�RA�INFORMA�'f0[�: r
<br /> Job Site Address: Z�l rj� ���� I�V rl rG��� � a � �� o lu/U �c3��
<br /> Vl/itl this be a F'arade af Homes, Remodelers Showcase �orne or ather Display Hom�7 ❑ Yes No
<br /> If yes,a speGz�l evont permr't is�quir�d with Police Departmenf and C;ty Counc,�approv�l 6Q days prior to fhe cv�nt. Shuftle buS senrice �!1/be
<br /> requlred unless applrcent d�mOnstrates suft7clent on-sRe parldng fs available. Non-permitted events wll!not bo aJ/owed,
<br /> COfVTRACTOF2/APP/�,�ICANT INFORMATfON:
<br /> Name: ``'��.�����. �.V S�� ��� . ....__ ,,.._
<br /> State License# G¢,1��-�,�� Expir�tion Date:
<br /> Lead C�rtification Number: �xpiration Date:
<br /> (for work on homes tha#were consrructed prior to 1975 ����
<br /> Phpne: (cell) � (office) ���-� �j� ��g
<br /> Mailing Addr�ss, �p�d �t1V (o City: ,ZiP: � _�
<br /> Contact Person: r - Q -� Applicant is: n actor / Nomeowner �circ�o one�
<br /> EmBil 8t1d/OI'Fr�x: C,�1F � II�; "J(�-GpM
<br /> PROPEPTY 01NN��NFORMAi 10
<br /> Name: � �P.�''� "� h � _..
<br /> I�hone (day)' �'2�. 92.� � ll $y
<br /> Address: _ �Z� S� ��r- t�V_,rl ��'�� � �.r Ciky; Q�/Jr7� _ZIP� jr,7��j�0
<br /> Emaif and/or Fax: �� i �.Co
<br /> PROJECZ 19VFORIV�ATpON: Ouerall ro'ect descri tion�
<br /> Type of Project: Any e rkh movement may also rcquir�
<br /> '�D�or(s) ❑F2emadel �Fire Damage Mcwp review 8�permRts:
<br /> ❑ �te-roof,asphalt ❑ M�opair � Storrn �amage M;nn�haha Greek Watershed Dlstrict(MCWb)
<br /> 1�320 Minnetanka�ivd
<br /> ❑ Ro-roof,cedar ❑ Restoration �Water Damage Minnotonka,MN 553�i5
<br /> ❑ Re-rooP, other(spec�ijr) ❑Siding ❑ Other, (specify) Phone: 952�71-0590
<br /> Fax; 952-471-b682
<br /> [�Window(s) www.minnehahacre�+l<,ora
<br /> Estimated Construction Vafuation of Project(excludio�g Cand) $ Z`I '"1 �`Z.
<br /> APPLIC6\IVT ACKMQWLEDG�M�NT:
<br /> • Agrees to provide all information required or requested by the Buiiding D�partment;
<br /> � Cerifies that the information supplled is true and correct to th�bost of hislher knowledge. The appiic2nt rec❑gnizes t'�at they are I
<br /> solely resporrslble for submitting a compl�tg appfication being aware that upon `aiiure to do so, the stafi has no alternative but to
<br /> reject It until if is complete;
<br /> � Some or a'I of the information that you are askod to pmvide on this application is classified by State law as elther private or
<br /> � confdenilal. Priv�te data fs information which generally r,�nnot be given to thc pubfic but can be g}ven to the sub.ject of the data,
<br /> ConfidEntial dat� is inform�fion whlCh generally Cannbt be given to oithcr the pubfic or the sUbj?Ct of the d�t�. Our purpo;e and
<br /> intended use of this information is to annually update our records and records of other govornmantal agencies required by 1aw. if
<br /> ou ref��se to su 1�ihc info ian Che application may not he issucd. _�
<br /> Applieanfs Signat�ar�; ..- --_-- Date: ���(�_..,..,._.---.
<br /> Owner's Signature; ��te;
<br /> 1.�st Clpdated;Januery 2013
<br /> ���,.y..,�.,.,,�...,�.��.,._._— �,._ _. �„_„----� ---
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