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<br /> E�������� E������ �.�a��������r� ��� f����������� � �er�Q�a����
<br /> (vvic�ao�.ps, �ioa�s�, si�iic�g, �-a-rar�f, ��c.}
<br /> ��� Mailrng Ada�-ess: I o o �-U l Z",G;C;��.�ol(y
<br /> „ � P„rmitnurrib„r: d
<br /> i'��`r' � � PO Bo>:oo �
<br /> /� (��� Crysial Bay, MN 5532�-0�66 i Date received: �' 2' /
<br /> � , I, i
<br /> �„� �� ;�,�' i a (.Receiv�d b� � � �
<br /> � ,� , Srr,.et Address: �
<br /> \r `�n' 'wr�'" <4 '
<br /> ��� � �'� . ��/ 27�0 Keliey Parkway Pfan:review ree: �---�
<br /> `�.rr ��'''g^� Orono, MN 55356
<br /> ESH� � �
<br /> G o-� To�al;Fe�: -,`�-���/ • D U
<br /> _ Main: 952-249-4600 ax: �_-249-4016 www.ci.orono.rnr..us
<br /> This appli�ation rorm must be completeo in r"ull and all required informafion must be submitted.
<br /> incompfefe appiicaiions will be returnec�. (Please print)
<br /> u`h�P.A� INFORMATIOh�:
<br /> Job Site Address: 3�j�j0 �o�c �j�-v�e-�� Q�-r,,,�o /Vt� �'� �j�j(a
<br /> Will tnis E�e a Parade of Fiomes, Remodeiers Showcase Home or other Disp{ay Fiome? [; Yes � No
<br /> If yes, a specral event permit is required witn Foiice Depanment and City Council approval 60 days prror to the event. Shuttie bus service wif!be
<br /> required unless app(i�anf demonsrrates sufiicienf on-site parking rs available. Nor-permitred events will not be allowed.
<br /> CONTRAC�'OR//�PPLICANT INrOP.MATIOt�:
<br /> tvame: �jt-�-��,r � �o �l �,.��.�-�. l,�--�- _
<br /> S,ate License # F3L pd3� a � Expiration Qate: 3 3 � �o
<br /> Lead Certiiication Number: �cJ�ps Expiraiion Qate:
<br /> (for work on homes that were constructed prior io 297B
<br /> Pnone: c��j� - �-� 3 - S Y 3� (of�ice) �� a — �r y - S 1 f 3 (c�ll)
<br /> Naiiing Addr�ss: ( �3 D IM:,,",�-t-�w�.c� I�� vc� , City: � Z�-I-z�IP: �5 3�
<br /> Contact Person: �� �,,,.,,�,�, ,�� Appiicant is: ontractor / Homeowner (�ircle One)
<br /> cmail and/or Fax: ��( ",,,;„�,;Sk„c� � r a� 5-�-�;,,��-� (�n „�,.�
<br /> V�p e- ���.�. • c,o
<br /> - � �
<br /> PROP�RfY OWN�R INrORMaTl01�:
<br /> �
<br /> Name: �a�c. ..� i �1°S
<br /> Phone (�ay): .
<br /> Ada��ss: 33�o 'Fox. �✓��-t� Ciiy: �,�o v�.� ZlP� r'J�J�J �(p
<br /> Email and/or Fax
<br /> PRQJ�C�' IN�ORM�eTl01�:
<br /> Type of Project: ', i i Any eartn movement rray require
<br /> ❑ Door(s) � ❑ Remodel , ❑ Fire Qarrage i MCWD review&permits:
<br /> ❑ Re-roof, asphalt i ❑ Repair Ninnehaha Creek V1/atersned District(MCWD)
<br /> ❑ Storm Gamage I 1 E202 Ninnetoni:a Blvd II
<br /> ❑ Re-roof, ce�ar � ❑ Resto�ation ❑V1(ater Damage I Geeohaven, MN 55391
<br /> � �, Pnone: 952-471-0590
<br /> ❑ Re-roof, other(speci"ry) � �Siding ❑ Other: (specify) I r-a>:: 852-47i-Oo82
<br /> I �
<br /> ❑Window(s) � ww�n�.minnehahacreek.orq
<br /> ; � ; i
<br /> Ove�all Fro�ect �escnpi�ort: lZ�v�o�e- -2X. is-Fi I,o�r��l� �.�c1 1'e.- (o+'i�l�
<br /> �stirrated Cor.strucfion �`afuaiion o` Projecf (er.cfuciing fan � �j� c_�jp . ��
<br /> �4PP�IC�t�T l-iC��f�OVI�L�aG�M�hE i:
<br /> • Agrees to provide afl inTorma'tion required or requested by fne Building Department; ,
<br /> • Ceriifies that the inTormaiion suppfied is irue and correct to the best or" nis/ner knowledge. Tne appficant recognizes tnat they ��
<br /> i are solely responsible for submitfing a complete appfica'tion being aware that upor failure to do so, tne staff ras no aliernaiive !
<br /> but to reject it unfil it is complete; i
<br /> I � Some or all o�the informafion that you are asked to provide on tnis aopiication is classifiec by S'tate iaw as eiYner private or I
<br /> confideniia;. Private da;a is inTorrrafion wnicn qeneraliy cannot be qiven to the pubiic but car be qiven to the subiect of the �
<br /> data. Confidenfial daia is informafion whicn generatiy cannot be given to either the pubiic or tne subjec: o` tne cata. Our ',
<br /> � purpose and intended use of this informaiion is to annually update our records and records or otner povemmen;al agencies
<br /> reauired b�� faw. If vou refuse t supo f n rmafion,the a�oiication mav not be issued.
<br /> flppli�anf's Sigrature: Date: �j /o2G� 1 2�
<br /> Las:upcated: DE•-OS-201"
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