|
.. ,}:" r .:'c1't' F"" ;'1,T ' ti'J `.+C-.-' f :
<br /> � . � . ' . .. . �
<br /> �t�� �f ����� . ,
<br /> ���i���� E��r�E� �,��a�������c� ���- �����ar��r�c� � �er�c��sa����
<br /> - . (v�i�aav���, �ioa€-�, si�ir��, ��-r��f, ��c.) C� � � �
<br />°�� � �
<br /> o` /� MarIrPO Bo�r 66 i Permitnumber. u
<br />� ' �� � Q� Crystal Bay, MN 55323-0066 ' Qate received:
<br /> 3
<br /> (� �� -�'` s. � S'rreet Address: ,� Receivsd by:�� � �� f� s
<br /> ��'�r ���'� ,ti o ';
<br /> \�cn �f,�. �/ 2750 K,.Iley Parkway � Plan:review fee: �
<br /> "�rzEs�'04'� Orono, MN 55356 -�
<br />`= Total':Fee: �
<br /> M�ain: 952-249-4000 Fax: �52-249-4010 wwv<<.ci.orono.mn.us
<br /> '; This appfication rorm must be compfeted in full and all required informaiion must be submitted. �
<br /> incompfete appficaiions will be returnecl. (Please prrnt) '�
<br /> u��l=RA! INrORMA'f"IOn: �
<br /> Job Site Address; 2� �Q L- �TTL�— �►t C/�/�'12� �/a�' �
<br /> p�f' Will ti�is be a Parade or Fiomes, Remodeiers Showcas� Home or other Display Nome? ❑ Yes I��fo �
<br /> 1f yes, a special event permit is required witn Police Departmenf and Crty Council approval 60 days prior to the evenf. Snuttie bus servrce wil!be
<br /> ' required unless applicant demonstrates sufiicient on-site par'rcing rs available. Nor-permitred events will nof be aliowed. �*
<br /> t,
<br /> CONTRAC�OR!�PPLICANT WrOP,MA IOf�t: �
<br /> Name: � A Y Gv E7V�O� ,:
<br /> _ �
<br />�% State License # �xpiration Cate: '°
<br /> Lead Certificaiion Number. A� �
<br /> Expiration Cat,,. �
<br /> (for work on �►omes that were construcfe�'prior to 1978 �
<br /> Phone: Gj Z,�` Z,�' Z� � (ofiice) (cell) ,'
<br /> Maifing Address: '� L, b ��tY� W q, ZIP: 5'�^� �
<br /> �
<br /> Contact Person: Appiicant : Contract r / omeowner (Circfe Gne� .�
<br /> 6.P
<br /> Errfail and/or Fax: � G� � W e1�S p.y� (J p� /1�(p�� � � CO/�l
<br /> _ �
<br /> ,�
<br /> �� PROPcR�"Y OWNER INFORMl�,�IOht:
<br />� : ,
<br /> Name: _ •.� G. �I �l/�1-2r'1.50'�. �
<br /> Phone(day): C� �-L Z3 Z--1 � . i
<br /> ; F�ddress: � _l--'� '
<br />; ° 2 � City: (�.�a, ZIP: �q �
<br /> Email and/or �ax J S :�
<br />� ,
<br /> . c �
<br /> PRQJ�CT IfV�ORMlt,�lOt�: :�
<br /> �. ' Type of Project: j � � L�ny earth movement rr,ay require �
<br />' ' , ❑ Door s MCWD review&permits:
<br /> � ) �temodel , ❑ �ire Camage
<br /> � � Ninnehana Creek V1.'aiershed District(MCW D) °
<br /> :� ❑ R e-r o o*, a sphalt �Repair ❑ Storm Damage ! 15202 Ninneionf:a Blvd �
<br /> ❑ Re-roof, cecar ❑ Restoration ❑V1�'aier Gamage Deephaven, MN 55391 :�
<br /> Phone: 952-471-Q590
<br /> ❑ Re-roof, other(speci"ry) ❑ Siding ❑ Other. (specify) Fax: 952-471-DoE2
<br />�°� E ❑Window(s) � www.minnehahacreek.orq
<br /> Ove�alf Froject DescripfiaR: (��Q w ,` w o� � e Q ��
<br /> =siirriatecf Cor.struciion �'afuaiion of Froject (.. ciucfing ;and) $ a � �
<br /> p?�!IC�I�T ��Fvi��1J1pL��f��M�P��:
<br /> i � Agrees to provide all inTormaiion reouired or requesied by tne Building Department; .,.
<br /> • �.eriiries tr,at the inTormafion suppfied is true and correc� to Yne best of his/her knowledge. Tne appficant recognizes tha: tney '� >�
<br /> are solefy responsible for submitiine a complete appficafion being aware that upon �ailur�to do so, the staif has no aliernative I
<br /> but io rejecf it until it is complete; i
<br /> � y
<br /> � Some or ali o.`tne informaiion tr�at you are asked to provide on tnis appiication is ciassified by S;ate law as eitner private or I� �_
<br /> �onfidential. Private da;a is inforrr�ation wnich generaliy cannot be given to the pubfic but car be qiven to the subiect or"the �I �4
<br /> " da.a. Confideniial cata is informatior, whicn peneraliy ;,annot be given to eitner th� pubii� or the subjec't o� tne cata. Gur �� �:`
<br />�,: purpose and iniended use of this informafion is tc annualiy update our re;,ords and records of other qovernmen;a! agenci„s '�
<br /> A �
<br /> �' ; reauired by law. If vou reruse to sup�iv tne inr"ormaiior, ' e anpfication mav not be issued. ��'
<br />'::�:: °,�
<br /> �pplicanYs Sigra'ture: Qatv `Q_(�,- 2-D�Z a
<br /> '.
<br />�
<br /> �as±�pda[ed: 08-DS-2D1, �
<br />��
<br />..
<br />�t..� _ _ .
<br /> . ... . , _„ . _ � ,.. .F...,. ., .. .�a.�
<br />
|