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<br /> .� (vvic�cio�.��, �ioo€-s�, �i�ing, ��-raof, �cc.) �
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<br /> ; M,arlrng Adaress: �
<br /> i��—� Permitnnumber. �j 2 `��
<br />� ��-�w'd� � PO Box 66 � _ �
<br /> /� ��� Crystal eay, MN 55323-OOc�6 ' Qate recei�ed: _ �����l:� ��.
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<br /> I\� �"� � ,�`� ti � Sireef Address: R�ceived by �
<br /> ,�c��F,��„ ��/ 2750 Kelley Parkway Pian revie ree: ��
<br /> "�.rt�sHo�'� Orono, MN 55356 � �� �
<br /> Main: �'52-249-4640 Fax: °52-249-4616 �,,�.� . To:al Fe � � ��S �
<br />= i orono mn.us r,
<br />� ' This appfication rorm must be completed in full and all required inforrra'tion must be submitted.
<br /> ^ incompiete appfications will be returnecl. (Please prrnt) �
<br />�' ��f��PA! INFORMATIO�: �
<br /> # Job 5ite Address: �j�:��, r 1
<br /> C.��.,��� � (
<br />�'` Will this be a Parade of Fiomes, R moe deiers Show ase Fiome or o�toer Disrlay Home? ❑ Yes f�o
<br />�' !f yes, a special event permit is required wifh Police Depanment and City�ounci!appr�va!60 days prro,�to the evenf. Snuttie bus service wi/I be `
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<br />�� required unless applicanf demons"rrates sufricient or-site parlcing rs availabie. Non-permitted events will not be aliowed. i
<br /> r ' CONTRACTOR/� PLICANT INFO .MA�IOR�: , ��
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<br />,�; fvame: n�'� �� s ��
<br /> ' State License # � , - G�S-- cxpiration Date: �� �
<br />" Lead CsrtiTicafion Number: o: �
<br /> Expirafion Cat„ �,
<br /> (for work on homes fhat were constructe�'prior to 1978 ��
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<br /> Phone: � -� �c,1 (ofrice) (cell)
<br /> } Naiiing Address: ��,- ;�) � City: e�� ZIp: s' L �
<br /> ' � �� � S� 7 / *
<br /> �� Contact Person: yQ,t,� ,. o ,.. ��
<br /> Apqficant is: Contra„t r / Homeown..r (.,ircle Une)
<br />�""' _�, �
<br /> �' Erriail and/or Fax: � �
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<br />�.: �
<br />��` PROPcR�'Y OWNER INFORMATIOf�: '�
<br />�: Name: ;'�f1 f� ���'3[�4 �
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<br />��; Phone(uay): • ;�
<br />��� Address: ��Zf�� / �
<br /> 6 l�L�1�S'� �/�� _ City: ��1 �� Z I P' ����l �
<br />'��� Email and/or Fax �
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<br />" � PFZaJ��� IIVFORM�t,'TIDf�; �
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<br /> ; Type:df Project: , i Any eartn movement rnay require '�
<br />� ` '�C{�D (s) � ❑ Remodel � Fire Damage I MCWD review&permits: �
<br /> � j Ninne ha ha Cree l:V 1,�aters he d Distric t(M C W D) "
<br /> ; Re-roof, asphalt �-�epair ❑ Storm Damage 1E2G2 Ninneioni;a Bivo �
<br /> 3 ❑ Re-roof, ce�ar ��j Res raiion aier Gamage Deeohaven, MN 55391 ,�
<br /> � Phone: 952-471-Q590 �,:
<br />� '
<br /> � ❑ Re-roof, other(speci'ry) � i g ❑ Other: (specify) =ar,: 952-47i-Do82 �
<br /> ,
<br />�?" � Window(s) � I www.minnehahacreek.orq �;
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<br />�` �' �Ove�all Froject fi�s�ripiic,r: C=�• �� � ,'1 ,,,., r� �' v /Z�%S� -F� / r� l'-+ - ' c� Z
<br />`�' �1 � � n l Ck'�.� �a�
<br />�r =siirriated Cor�struciion �,°aivaiion of Proiect (�x^iuciing Eand) � � , i��, �( �w,� i i ,
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<br />�,`' �4PPLI���47 �,CF�iV01/1lLc�:��IVi�P�i: S
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<br />�, : � Agrees to provide all inTormafion required or requested by fhe Buifding DeFariment;
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<br /> �,. • Certifies tnat the informafion suppiied is true and correct to tne best or" nis/ner knowledge. Tne applicant recognizes tna: fhey �
<br /> �, are sofely resporsibl�fo�submitiing a compiete app(icafion beinq aware fr,at upon ;ailure to do so, the staff has nc afternaiive j
<br /> '- but to reject it unfil it is compleie;
<br />�', � Some or all of the information that you are asked to provide on tnis aoplication is ciassified by State iaw as eitne� priva"t� or I�I
<br />�,.s I conridentiaL Private da,a is informaiion wnicn generall�� cannot be given to the pubiic but can be given to tne subject of the �
<br /> ' da�a. Confidenfial da;2 is informatior whicn generally cannof be given io eitner tne pubiic o� tne subiect of tne data. Our
<br />�Y purpose and intended use �f this informafion is to annualfv update our records and records of otner aovemmen;al agencies ^�
<br /> required bv lav��. If yo reruse to su af tne inrormafior th pii�aiion ma�� not be issued. ,��
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<br /> : Last Updated: 08-OS-2D11 ��
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