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<br /> � t ' ���ic���g E��r�i� �,p��E�c���c�� ���- 6`���r���r���e� / �er�c��at��� � x�r ��.
<br /> (vvi�aov�p�, �ioa�-�, sie�ir��, �-�-ra�f, ��c.)
<br /> �, Q� M,ai(ing Adaress: � Permit number: 0��02-O�l� M
<br /> �
<br /> %' PO Box o6 �'i
<br /> y%'
<br /> C s�al Ba MN 5532 -DOo6 , � � � `''
<br /> �� � Q\ rY � Y, 3 Cat., r..ceiv.,d: / -- �. /� �;
<br /> Y �b�:_ I ;" Receivea b ; i';
<br /> ���� �� � s. ; Streef Address: Y
<br /> \'�� �' �s"� �� 27�0 Kelley ParkwaY o 0 oQ r�'
<br /> �.�� \��,�+�, / Pfan r.,vi.,wr.,,:: {.
<br /> �Esxo4`� Orono, MN 55356 �
<br /> Main: 952-249-4000 �ax: 952-249-4016 �,,�.� . To:al':Fee: � �J�l � ' E;
<br /> `' i orono.mn.us _ �;,
<br /> n.�
<br /> This app(icatior rorm must be compieted in full and all required inr"ormaiion must be submitted.
<br /> incompfete appficaiions will be returnec�. (P/ease print) _'
<br />� u��d=RA� INFORMATIOf�: (� ?
<br /> r Job Site Acidress: (� �� ��✓�� �"L,�. *�
<br /> Will this be a Parade of Ffomes, Remodeiers� ahowcas� Fiome or other �isp6ay Home? i_l Yes o ��
<br /> !f yes, a specia/event perrrtif is requirea with Poiice Depar[menf and City Council approval 6G days prror to the evenf. Snutfie bus service will be '
<br /> required unless applicant demonsf,�ates sufricient on-sire parking rs available. Non-oermitted events will not be aliowed. �
<br /> �
<br /> CONTRACTOR/APPLICANT INr�RMATl01�; �
<br /> fvame: �' �
<br /> T.�r-�� �C ���/ � �
<br /> S,ate License # � � � (��'� � �xpiraiion Cate: �
<br />� . Lead CertiTicafion Number: Expi-afion Qate: '�
<br /> (for work on homes ff�at were construcfe�'prior ro ?978 �
<br /> Phone: C?rc��7-1�--� —4�'3(.,��� (ofiice) (cell)
<br />� Maifing Address: �L �, � � City: ,��1 ,� ZIP; � 3 �
<br /> Contact Person: G" _1 , �
<br /> . �.xi.7'� �i��Q_(,L�� Appii�ant is: �'Cont�ac / HomeownAr (Circie One) �
<br /> Errail and/or Fax: �----� �
<br /> �
<br /> , PROP�RTY OWNER INc=/O� FZMl�TIO�t: �
<br /> : Name: 14���✓� k �c��g 1 �S�� �
<br /> Phone (day): �% .
<br />�i Addr�ss: � � City: C...���c� ZlP: �
<br />'' Email and/or Fax
<br /> � �
<br />�,, �
<br /> a Pr2QJ�CT IN�OrZM�t,�IOR:
<br /> ' Type of Project: � � i L�ny eartn movement rray require
<br />#` �
<br /> ❑ D or(s) ❑ Remodel I ❑ Fire Qarnage I MCWQ review&permits:
<br />�� I Ninnehaha Creek VI�'atershed District(M;W D} �
<br />= Re-roof, as halt I �
<br /> P ❑ Repair ❑ Storm Damage 1E202 Ninnetonl:a Bfvo :
<br /> � ❑ Re-roof, ce�ar ❑ Restorafion ❑Waier Gamage Deephaven, MN 55391 �
<br />" Pnone: 952-471-Q590
<br /> ❑ Re-roaf, other(specify) ❑ Siding � ❑ Other: (soecify) =a�c 952-47i-Do82
<br /> ,�
<br /> i ❑Window(s) www.minnehahacreek orq
<br /> Ove�all Froject �escrip"tiaR: I '
<br /> �:
<br />�:` =szirratecE Cor.strucfion 4�afuaiion o` aro�ect (excfuciing �and) $ �7 ��j �
<br /> ;,;�,
<br /> �,�
<br /> APP�I��►(�T ,e,CF�t�U1/�L�D��McP�i: °'
<br /> i � Agrees to provide all inrorrraiion required or requested by tne Building DepaRment; i
<br /> • �er�ifies tr,at tne inTormation suppiied is true and corre�t to tne best of nis/ner knowledge. The applicant rocognizes that they �
<br /> are sofely responsible for submitting a complete apoiicafion being aware tnat upon failure to do so, tne staff has no afternaiive I
<br /> but to rejec't it until i:is complete; _?
<br /> I �;
<br /> • Some or all of the informafion that you are asked to provide on tnis aapfication is ciassified by S;ate iaw as eitner privat� or j �
<br /> conrideniiaf. Private data is information. wnicn qeneraliy cannot be aiven to the pubiic but can be given to the subject of the I '�'``
<br /> ,� da�a. ConTideniial data is information which qene,aliy cannot be given to either the pubiic o� tne subject o` tne data. Gur � �
<br /> � purpose and intended use of this informafion is te annuali�� updatG our records and records or otner govemmental agencies � '
<br /> reauired b�� lati�. If you reruse to supafv tne inrormaiion, tne aoaiication mav not be issued. � �
<br /> ' -� / z,:
<br /> kpplicant's Sigr,aiure: Daie: l�—l`� ^(�
<br /> �zst Updatea: 08-09-2C^�
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<br /> ,. _ _ . _ _:. . ,.. ..,... �.,.., _ _ . _ _ _ ,.`.:.
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