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���� �f ��c��c� <br /> . _. <br /> ti �������� E������ �,��������c�� ���- f�a�€����a��� / �ec�cr������ <br /> ' ��I�1ClOV1.��, �C�aCS, Sl�irl�, �'�-CEa�f, �cC.} <br /> , Narirng Adaress: ' Permit number. �..Dl 2-D �/� <br /> ��-�v ��- PO Bo>:oo i <br /> %� � ��� Crys;ai Bay, MN 55323-OOo6 ' Cate receive�: //- O �-/ �� <br /> ' ��y-,t� Received b}�: <br /> �a �14 � �;� ;,, ,� Streer Address: <br /> '�'��n � '� 4��'�' �4/ 2750 Keliey Parkway Pfanrreviewfee: <br /> `t��Hho4'� Orono, MN 55�56 <br /> To:al:Fee: <br /> Main: ��2-249-4nOD Fax: �52-249-4610 wwvt�.ci.orono.mn.us <br /> Tn�s appfication rorm must be comqleteo in Tull and all required information must be submitted. <br /> incompfefe appfica"tions wii! be returned. (Please print) <br /> u�1��RA! INr=ORIUATiOt�: � `, <br /> Job Site Address: i ���5/' �i�'��/�-�`. ]f <br /> Will tnis be a Parade of Homes, Remodef6CS jf10WC8S9 Home or other Display Home? ❑ Yes J �fo <br /> !f yes, a spec;al even!permit is required wifh Pofice Deparrmenf and Cify Council approval 6G davs prior to the event. Snuttle bus servrce wiU be <br /> required unless applicant demonstrates sufiicient on-site parking rs available. Non-permrtred events will not be allowed. <br /> CONTRAC�OR!APPLICANT INrOP,MAT101�: <br /> hame: /�l%✓l�/�% �n.t�Sfj�uc_�� ��.r� <br /> S;ate License # � , �� � �/� /�!f �xpiraiion Cate: � �` 1� <br /> � � <br /> Lead Certificafion Number. ��� �xpiration Cate: �'� �,��s <br /> (ror work on homes that were construcfed prior ro 1978 <br /> Phone: �' - � QD (ofrice) (c�ll) <br /> Maifing Address: / s _fj �� �,� � Ciiy�]j � �,,��,� ZIP: ����� <br /> Contact Person: �s ��� �,�i Appficant is: on / Homeowner (CirGe One) <br /> cmail and/or Fax: �� " � , :J� <br /> PROP�R r Y OWN�R INFORM,4TIOt�: <br /> Name: f7�/A/5��.=Y S�t�/��iJ <br /> Phone(day}: ���� �. — • <br /> Address: �, - �� � Cii <br /> �.�- ZIP:��� _-' <br /> �mail andior �ar, <br /> PRC)JcCT IN�ORM�;,TIOI�': <br /> Type of Project: ! � Any eartn movement rr,a�r require <br /> r A � i MCWD review&permits: <br /> ❑ Door�s) I ❑ Remod..l , ❑ Fire Qamage � <br /> j � Ninnehana Creek V1.'aiersned District(MCW D) <br /> � ' Re-rooi, asphalt i ❑ Repair ❑ Storm Gamage i 1�202 Ninneioni:a Blvo <br /> i <br /> ❑ Re-roof, cecar ; ❑ Restoration ❑VUaier Damage Deeohaven, MN 55391 <br /> I i Pnone: 952-471-0590 <br /> ❑ Re-roof, other(speci"ry) ! ❑ Siding ❑ Other. (specify) ; =ar 952-47�-Oo82 <br /> I wwvv.minnehahacreek.or <br /> �I ❑Window(s) �; Q <br /> � <br /> Overall Project �escripiiar,: �j��� , (-� � —r p�� <br /> =siirr,ated Cor.struc�ion �,'aivaiion o� ?roject (exciucfing �and) � ��? ��� ���, <br /> :--- <br /> AppLI��9I�T r�CF�IVOVI�LC�;s����i: <br /> ; • Agrees to provide all informa'cion reauired or reouested by the Building Department; ', <br /> i • �eriir'ies tnat the informafion suppiied is irue and corre�t to tne besf or' nis/ner knowledge. Tne appfi�ant recognizes tna: they I� <br /> I <br /> are sofefy responsible for submitfing a compfete appiicaiion beinq aware that upon failure to do so, tne s�aff rzs nc afternaiive I <br /> ibut to reje�:it unfil it is complete; <br /> � � Som� or al! of the inTormation tr�at you are askec i� provide on tnis appiication is classified by State iaw as eitner privaie or '; <br /> confideniia;. ?rivate data is inrormation wnicn qenerali�� cannot be given to the pubiic but car be given to the subiect of the '� <br /> , da:a. Conridential data is information which gene;ali}� cannot be given to eitner the pubiic or the subiect o` tn� caia. Our i <br /> purpos� and intended use of this information is tc annualfy update our recores and records oi otner governmen;al apencies ', <br /> reauired bv taw. If vou retuse to suppfv the informatior,. the aoqiicaiion mav not be issued. ' <br /> f <br /> �pPIICan`.'s Sigrature: `�������.���ll�—� Date: 1� /�- <br /> Last Up�ated: 0�-C9-201^. <br />