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Feb 25 09 01;46a DEVEAN GEORGE 9728699970 p,1 <br /> . � <br /> � � City af Orono <br /> Building Perr�tit applica#ion <br /> �-"'ti M811i�g Address: Permit nurnbet; �� - 000 <br /> �Q.�� PO Box 66 <br /> +�Q a Crystal Bay, M�V 55323-0066 Date received: Q <br /> 1 '� - <br /> - � Straef Address; Received by: -'� � <br /> �� 2750 Kelfey Parkway Pl�n review fee: '`��; <br /> ��c�o�� Ocono,M�155356. <br /> Tofol Fee: '� c- c - � <br /> , Maire: 952-249�F600 Fax: 852-349-4616 www.cl.orono.mn.us � � C; _> '� '' ' <br /> This applicaUon form must be compketed in full and all required intormatiDn must be submiited, <br /> Incomplete applications will 6e retu�ned. (Plea56 print} <br /> G�NERAL�NFORMATION: <br /> Job Site Adaress: _ 10� � � F�e n�G L C�2.ce!� �� OF'��,d 1�'1,�.� ���� � <br /> �/Vill thls be 2� i'arade of Hom�s, Remodelers Showcase Home o�other Display Home? ❑ Yes [; No <br /> N yes, e specie!e venf permit is requi�d with Pp/k�9 pgparG�enr and Cily COun�Jf appNval 60 ddyS prtOr to!hB Oven� Shuttle bus serace�N,rr bo <br /> requirad unlass&pplicdnt dernar�s�iatas s��ciant on��ile perYcir+Q is avadaDfa. IVan-petrnrded evenls wil/nat be allorvBd. <br /> CONTRACTOR/APPIICANT INFORMATION: , <br /> � Name: <br /> State License�l � Expiration Dats: <br /> Phone: (aFfice) (cell► <br /> Ma�ling AdGresS: - City� Z�p: <br /> Contact Perso�: Applicant i5: Cos�tractor / Horrteownef �cu��e Qr,a� <br /> Email andlor Fax: <br /> PROPERTY OWNER IN�ORAAATI�N: <br /> �lame; 1�r_Jtr,a/ ��drSJ�- <br /> Phone(daY): In_L�- �y r -I L 3"1 � -- <br /> Address: 1�o,S��Q�„��, ca r �R city�ora wv z�P , .�3 9( <br /> Email and/ar Fax ► <br /> tJtaN�`i^v"fd��' Y4����� "� � 1���77�V��� <br /> PRaJ�CT INFORMA7'IpN; ` <br /> ' Type oF Project: Any earth rnoventent may require <br /> MCWD review 8 permitS <br /> ❑ Oaor(s) �Remodel ❑ Water Damage <br /> Minnehaha Creek Watershad District(MCWD) <br /> ❑Windaw(s) (] Repair ❑ Starm Damage �82Q2 Minnetor�ka Blvd <br /> Deephaven,MN 55391 <br /> ❑Siding ❑ Restoration . ❑Other: (spe�ifyj Phane: 852�71-D59D <br /> FQx; 952-471-D662 <br /> ❑Ra-roof ❑ Fire Damage www.minnehahacreek org <br /> Overdll Proj�ct Description: ' <br /> Estimated Constructioh Valua#ion of Proj�ct�excluding land) S . v�; "J <br /> APPLfCANT 8� OUVNER ACKNOWLEDGEMENT: <br /> • l�grees to provide all inf�rmation requ�red or requested by the Bsuding�epariment, <br /> • Cartliy thac the informalian supplied is true and correct to the best of his/her knowledge. 7he applicant and owner recosnize <br /> that thay are solely responsible for submitting a eomplate application being awarr that upon failure to do so,tho ataff <br /> has no alternative but ta reject it until it is complete. <br /> • The Owner hereby acknowlodges and agrees lo this applical+on and f�rther euthorizes reasonable entry onto the propetty by <br /> City Staff,consultants or agents,for purposes of investigAtion of this requesl. <br /> � Some or all of the informai'ion thac you are asked to provide o� this application is �lassified by State Jaw as eilher private or <br /> contdentiel. Private data is informatlon which generally cannot 6e givan to the publie hut can be given to the suhject o!the <br /> data. Corrtidan:ial data is infprmation which generally cannot be given io either the public or the subjact oF the daca_ Our <br /> purpose and intended use of this ii�formation is to annually update our records anc records of other gov�rnmental egencies <br /> re uired 6 iaw. If ou refuse ta su I !he information,thc a lic�Gon ma not be issu�d, <br /> Applicant's Signature: _ Date: a �a �d ! <br /> Owner's Sigrature: __ _�/� �,,�e; �'� �-_D� � <br /> �� '�--------_ _.. ., ,�c � — <br />