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JUL-21-2011 10 :47 AM WALKER, ROOFING 6512510916 P. 01 <br /> � • ww��w��.a � ������� I1�/F/��VY6�V�1 IV� ���av���a� rrv�R <br /> windows, doors, sidin , re-roof� etc. <br /> �J-r=•, Mailing Address: <br /> 'Q�d.� PO Box 66 Permit number: � <br /> Q Q Cry8tal Bay, MN 55323-0066 p�re�iy�; �a� l <br /> � �` Streef Addr�as: Received by; <br /> � �� 2750 Itelley Perkway Plan review o: <br /> o� Orono,MN 55358 <br /> �:�..-_:� ��. 39 <br /> Meln: 952-248�800 Pex; 952-246-4816 www.ci.or000,mn.u_ To�l Fee: <br /> Thia appllcation form must be completed in full and all required informstlon muat be submitted, <br /> Incomplete appllcations wlll be returned, (PleaBe print) <br /> GENERAL INFORMATION: <br /> Job Slts Addr�eas; L �� <br /> WIII thls be a Parada of Momes,Remodol•�8howcase Home or other Dlsplqy Home? Y�s No <br /> !I y�a,a apeda/eve�psrml!Is►squl�ed with Po/!�y pepo�nc and Clfy Councll app�ve/QO days prbr Up th.eiro� ShuttlB bus sNWce w�l be <br /> requl�d unls�e wppNCar�t drmonskatea BufAcls►�t orra�e ps►kMp Is syellsble. Non pen►Jl�ed events wIN not be allo►�d. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: i,J q�k <br /> Stete License# N�� Expiretion Date: � <br /> Lead Cenlflcatlon Number: _ _ q � Expir�tion Date; <br /> (!br wor,k on homei that ware conatnucdod pr�oi to 19 B � <br /> Phone: 65 I ��Z'S ( •- aq t a (office) (cell) <br /> Meiling Addrose: City: ZIP: <br /> CoMact Peroon: Applicent is: ontracto / Homeowner �ciroa o,,.� <br /> Emall and/or Fax: <br /> PROPERTY OWNER IN�OFiMATION: ' <br /> Name: � <br /> Phone(day); 5'L�4 7 2 — �4 ")l <br /> AddresB: 4 5 L cE L�n�£ arDG,E City Ihq-A�,E Pc.M�'ZIP• 3 S y� <br /> Email and/or Fax <br /> PROJECT INRORMATION: <br /> Type of ProJ�ct; Any sarth movamont may requ ro <br /> ❑ Door(s) ❑ Remodel �Water Damape M����ew 8 psrmlb: <br /> ❑Window(6) ❑Re alr Mlnneheh�Creok Watershad District(MCWD) <br /> p ❑Storm Damege 18202 Minnatonka Blvd <br /> ❑Slding ❑Resto�ation ❑ Other: (epecify) P one�V952•471-Ob90 <br /> �$e-roof ❑ Flre Damege Fex: 952-471-D66Z <br /> www.minnehehecreek org <br /> Ove�all ProJact Deacrlptlon: +►-��.�L b�t�C W,.�� ee+� F_�_,L¢� �fe v5� <br /> Estimated Con�tructlon Valuatlon o�ProJoct(excludl�p land) S � �, 7 7q _dd <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • p►prees to provide all inbrmation required or reques�d by the Bulldiny Departmenh <br /> • Certiflas that the InfbrmeUon �upplied is true and correct to the best of his/her knowl�lpa. The appllCent rocognlzes that they <br /> ere 9oltly responsibla for submittln8 a complete application b�ing ewere that upon failur�to do so, the stafl hes no alteme tive <br /> but to reject It untll It lo complete; <br /> � Some ar sll of t�e information that you aro eoked to provlde on thla epplication is cleatlfled by State lew as eitner prtv�te or <br /> confide�iel. Prlvete dote le information whlch penerally cannot be Qiven to the public but c�n be glwn to the subJect of the <br /> data. Confldential dats la Information whlc� �enerelly cannot be �ivon to elther the publlc or the subject of the dat�, Our <br /> purposa and ir�ndod use of thl9 Information le to annually updebe our records and recorclg oF othsr govemmental agencles <br /> uirod b law. I U refuee to su I the i rmatlon the lica io ma not b ie ed. <br /> Applicant's Signaturo: � Date: � � / <br /> Laet Updpled: 03-01•Z011 <br />