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<br /> B��Ic�ir�g Pe�c�6t Q,�����a��Qr� �ar I�Eair��er�a€�ce l F�er�ava�iara
<br /> � (winafov��s, doors, siding, �e-roof, e�c.)
<br /> � ��� M,ailing Aadress: ' Permit number: 020<a-0/�7� �
<br /> �' � PO Box 6r3 '
<br /> �(� �\ (� �� Crystal Bay, MN 55323-0066 �Date received: ��-��'/.�
<br /> , � L
<br /> �,a I��„'' �, Street Address: Received by �-�
<br /> �� '�`'f F,` a �� 2750 Kelley Parkway �y Plan reviewf e:
<br /> �`LA.g� Yo�'� Orono, MN 55356 i1��`
<br /> SH 0 _ _ . � �U/ /. .'. .�. .� .
<br /> Total Fee: � 3
<br /> Main. .,52 249 4000 Fax: 952-249-4016 wwv,�.ci.orono.mn.us
<br /> This appiication form must be completed in full and all required information must be submitted.
<br /> incompfete appfica�ions will be returned. (Please prrnt)
<br /> G�NcRAL INFORMATIOAf: „
<br /> Job Site Address '�%' (', -
<br /> `�.%c.'
<br /> Will this be a Parade or Fiomes, Remodefers Showcase F1ome or other Display Home? ❑ Yes � "�No
<br /> lfyes, a specfal event permit is required with Po(ice Deparimenf and City Council approval 60 days prior to the event. Shuttle bus servic�e wil!be
<br /> required un/ess applicanf demonstrates sufr"icient on-site parking rs available. Non-permitted events wi!l not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATIOI�:
<br /> Name: ;�i � .. � , �
<br /> �. •T !;( - ay,.�;�,
<br /> �,..w ,.,(�, 'r':`��J `,,� = ,�;,r`
<br /> S,ate License # j sy(� ,_ c,,,r� .,`��� Expiration Date: z,' � !���j��
<br /> Lead Certificafion Number. �.��_ _ � �t ��, ; :: 1 -- I Expiration Qate �;''?���`;;`�.-�
<br /> (for work on homes that were constructecf prior to 1978 '
<br /> Phone: _ -->ti�� --; ci C.._� (ofiice) -' < ��7 <-' (c�ll}
<br /> Maifing Address: ��,��� � , ,, �n� �, -, ,
<br /> � r �-t-. City. � ��`� ���y,;�1<i ZIP� �L' 7 ,''
<br /> Contact Person: ���..�{�� Applicant is: Contractor T� Homeowner (Gircle One)
<br /> Email and/or Fax: /
<br /> C_-
<br /> PROPERTY OWN�R INFORMATION:
<br /> A• �, • , _ _ r ,
<br /> am... K.- � �' �� ���c'o1�'l� �*'' �, �,<����
<br /> Phone(day): <<S�. - `�7C) � i ' � .
<br /> Address: ry!r J�:. �' � �-,yt' , , ;.�� . City: ;� � ZIP�
<br /> Cl - � y.� �..
<br /> Email and/or Fax
<br /> PRaJECT INFORMl�TIOl�:
<br /> Type of Projecfi � I �ny earth movement rriay require ,
<br /> ❑ Door(s) �yRemodel I ❑ Fire Qamage I MCWD review&permits:
<br /> Minnehana Creek Watershe� �istrict(MCWD)
<br /> ❑ Re-roof, asphalt � Repair ❑ Storm Qamage � 1 E202 Ninnetonka Blvo
<br /> ❑ Re-roof, cectar I ❑ Restoration ❑V�,'ater Damage � Deephaven, MN 55391
<br /> � Phone: 952-471-Q59�
<br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other. (sqecify) I Far.: 952-471-0682
<br /> � ❑Window(s) �; www.minnehahacreek.orq
<br /> Overall Froject DescriptioR; ����� �,� � �� �,��� ��t � �
<br /> �sfirriated Construcfion Vaivafion of Froaect (excfuciing fand) $ ���� ��C �:.---'---
<br /> APPLI��►t�T ACKfVOWL�DE��M�I�T:
<br /> • Agrees to provide all informaiion required or requested by the Buifding Department;
<br /> • Certifies tnat the informaiion supplied is true and correct to the besf of his/her knowledge. The applicant recognizes tha: they
<br /> are solely responsible for submitting a compiete appfi�aiion being aware that upon failure to do so, tne staff has no alternaiive
<br /> but to reject it until if is complete;
<br /> • Some or all of the informafion tha: you are asked to provide on this app(ication is classified by S;ate iaw as eitner private or
<br /> confideniiaL Private data is informafion which generally cannot be given to the pub(ic but can be given to the subject or the
<br /> da,a. Confidenfial data is information which generalfy �annot be given to eitner the pubiic or the subjecf of tne data. Our
<br /> purpose and intended use of this information is to annually update our records and records of other governmen.al aqencies i
<br />� reQuired bv faw If you reruse to supofy the inTormafior tne apaiication mav not bP issu�d
<br /> ApplicanYs Signature: �_ .� Qat�: � ' �,
<br /> �= /� �i.7%-�--
<br /> Lzst Updated: 0�,-a9-2D11 �� � '
<br /> �.:
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