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���� �f ��a�� <br /> , . � ���6�ir�g P'er�i� Ap�p���a�iQr� �or NEair��er�a��e / �enQva�io� <br /> (winaov�rs, ciov�-s, siding, r�-roaf, e�c.) <br /> Mailrng Adaress: i <br /> ���,� PO Box oo � Permit number. /a—� <br /> / (�\ Crystal Bay, MN 55323-0066 �� Date received: �- -Z ' <br /> � � �., � <br /> ��� 4 �`��� � I' Street Address: �Receivetl by�: � � � ' <br /> \'�� ��'� `"�'� F 2750 Kelley Parkway o o. <br /> .,t i .�� o �fan revi,.w fe,.. <br /> � `�,k�SHo�''� Orono, MN 55356 <br /> Tota1 Fee: � `� � �� <br /> Main: 952-249-4000 Fax: °52-249-4016 www.ci.orono.mn.us <br /> This appficaiion form must be completed in full and all required inrormation must be submitted. <br /> Incompiete appfica�ions wiil be returnec�. (Please print) <br /> GENERAL INFORMATIO�: <br /> Job Site Address: ZIb L� ��W�c�� (!`� Dr°�o ✓�l� 5�:3 � � <br /> Will this be a Parade of Homes, Remodeiers Showc se Home or other Display Home? ❑ Yes No <br /> !f yes, a specral event permit is required with Po(ice Deparimenf and City Council aporoval 60 days prior to the event. Shuttle bus service wil!be <br /> required unless app/icanf demonstrates sufircienf on-sire parking is available. Non-permitted evenfs will not be allowed. <br /> CONTRAC�'OR/APPUCANT INrORMATIONt: <br /> Name: �4�X f�Vl VI�C- <br /> State License # gGb ��C� 3 b 3 Expiration Date: 3 31 D ( 3 <br /> Lead Certificafion Number: (�/�j� �2,2'L I� -I Expiration Qate: 3 '� L n � <br /> 7 <br /> (for work on homes fhat were coRstrucfed prior to 1978 <br /> Phone: 6 I Z- 2 `I�- 3 7�i (ofrice) (cell} <br /> Maiiing Address � (��y�.F..Qr i- �,r� City:(�J ;� ZIP: s j Z ,S`� <br /> Contact Person: J3 o b �✓;�(,a-�,.s�rl App(icant is: Contracto� / omeowner (CircYe One) <br /> cmail and/or Fax: 6 5`/ - �f o�7._ �p L S� <br /> PROPERTY OWNER INFORMATIOt�: <br /> Name: h'G-�� �li�.-��C s e-✓� <br /> Phone(day): �j 2 -6 y � ' �S�6 �� ° <br /> Address: Z l 60 /Gp,,,�,,,•oocQ L.�� City: ��e„i o ZIP: s $,3�� / <br /> Email and/or Fax <br /> PR�JcCT IN�ORMl��101�: <br /> Type of Project: ! Any eartn movement rrzay require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ,�Re-roof, asphaft ❑ Repair , $f Storm Darriage I� 1 E202 Minnetonka Blvd � <br /> � I I Deephaven, MN 55391 <br /> ❑ Re-roof, cecfar i ❑ Restoration ❑Vbfater Damage <br /> Phone: 952-471-Q590 <br /> ❑ Re-roof, other(specify) I ❑ Siding ❑ Other: (specify) Far,: 952-471-0682 <br /> ! www.minnenahacreek.orq <br /> � ❑Window(s) � <br /> Overall Project Descriptiort: %�. � S ,�o-.-� l-�-,-�, <br /> Estimated Consfruction Vafuation of Fr ect (exciucfing land) $ �/. 4c�G' � �`� <br /> APPLICAI�T ACKh10WLED�EM�P��': <br /> • Agrees to provide all information required or requested by the Building Depariment; <br /> • �ertifies trat the information suppfied is true and correct to the best of his/her knowledge. The applicant recognizes that fhey <br /> are soleiy responsible for submitting a compiete app(icaiion being aware that upon failure to do so, the siaff has no alternafive <br /> but to re}ect it unfil it is�omplete; <br /> • Some or alf of tne iniormation that you are 2sked to provide on tnis appfication is cfassified by S;a'te law as eitner priva'te or <br /> conrideniial. Private da;a is information wnicn gene�aliy cannot be given to the pubiic but can be given to the subject of the <br /> ca,a. Confideniia! data is information wnich generalfy cannof be given io eitner the public or the subjecf o` tne da;a. Our <br /> purpose and intended use of this informafion is to annualfy update our records and records of other govemmen;al agencies <br /> reauired bv law If vou refus�to suppf�tne inTorrrzaiion tne anpfication mav not b�i�su�d I <br /> ApplicanYs Signature: � �-- pat�. �Z � Z J t 2 <br /> �ast Uodated: 0°�-09-2011 <br />