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���� �� ����� <br /> - ` �e�E���r�� E�e��i� �,�p���c����r� f�r �a��������� / �er���a���� <br /> � (rn�i�aov`��, �iaa€��, sic�i��, �a-ra�f, ��c.} <br /> � Maiiing Address: Permit number. <br /> %�-� ,� PO Box 66 <br /> /� � Q�\ Crystal Eay, MN 55323-0066 i Date teceived: <br /> �" ��a t���P�-��,,'_`� s, � Street Adaress: i:Received by: <br /> a �\�t , �' F;'��`,� �/ 2750 Kelley Parkway � <br /> ��.t� � rr��'�� Orono, MN 55356 Pfancreviewfee: <br /> Esxo <br /> To:al'IFee: <br /> '' Main: 952-249-4600 Fax: 952-249-4010 www.ci.orono.mn.us <br /> Tnis application form must b� completeo in full and all required information must be submitted. <br /> incompiete appficaiions wiil be returnecl. (Please prinf) <br /> ��h=P.AL INFORMATIOI�: �� � �� <br /> Job Site Address: <br /> Wil! this be a Parade or Ffomes, Remodefers Showcase Home or other Display Home? i ! Yes No <br /> If yes, a specra/event permit is required with Poirce Deparfinenf and City Council approval 60 days prior to the event. Shuttte bus s rvrce will be <br /> required unless applicant demonsirates sufiicient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRAC�'OR!APPLIC NT INr P. ATIO • <br /> Name: (..�Y��(/�/C ����// k%� <br /> State License � �.�� �xpiration Qate: <br /> Lead Certirication Number: Expiration Cate: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (of�ice) (c�ll) <br /> Maifing Address: � Ciiy. Z�p: <br /> Contact Person: � Applicant is: Contractor om�e .�� (Gircfe One� <br /> �mail and/or Fax: - <br /> PROP�R i Y OWN�R INc l��IO�t: <br /> Name: J �✓ <br /> Phone(day): . <br /> Address: � City: ZIP: <br /> Emaii and/or Fax <br /> Pr?C)J�CT IN�OrZM�t,'TIOh: <br /> Type of Project: � I Any eartn movement rray require <br /> ❑ Door(s) ❑ Remodel I ❑ Fire Qamage I MCWD review&permits: <br /> j Ninnehana Creek Watershed District(MCWD) <br /> �Re-roof, asphalt ❑ Re air i <br /> F ❑ Storm Damage 15202 Ninnetonka Blvo <br />� :; ❑ Re-roof, ce�ar ❑ Restoration ❑V�,'ater Gamage i Deephaven, MN 55391 <br /> Phone: 952-471-Q590 <br /> ❑ Re-roaf, other(specify) ❑ Siding ❑ Other: (specify) ; Fax: 952-47i-Oo82 <br /> ❑Window(s) I � www.minnehahacreek.orq <br /> ' i <br /> Ove�alf Froject Des�riptioR: <br /> � _ �siirratec CoRs�rucfion 1,'aivaiion o� ?roject (exciuciing �and) � r <br /> APPLIC�t�T �CbCNOVlsL�D��M�Ri i: <br /> Wt - I � Agrees to provide all inrormaiion required or requested by fhe Building Department; <br /> �� � <br /> ;i • Cer�ifies tnat the inTormaiion suppiied is true and corre�t to the best of nis/ner knowleage. Tne appficant recognizes tra: they <br /> ;;, are sofely responsible for submitiing a complete appiicafion being aware that upon failure to do so, tne s�aff 'r�as nc alternative <br />,� but to reject it unfil i:is compfeie; <br /> � • Some or all o`tne iniormafion that you are asked to provide on tnis appiication is ciassified b�� Staie iaw as eitner private or �I <br /> confidentiaL ?rivate da;a is inTorrrzation wnich qene;ally cannot be piven to the pubiic but can be given to the subiect of fhe ' <br /> ida:a. Confidential daia is information whicn generaliy cannot be given to either the pubii� or tne subiecf oT fie da,a. Our i <br /> purpose and incended use of this informafion is tc annually update our records and records o� other aovernmen�al agencies � <br /> I required b��law. If vou reruse to supafv tne informafion,the a�piication rrav no�be issued. j <br /> App(iCanYs Sigra'ture: Cat�: ���� G �/D� <br /> �zst Updated: OE-Q9-2D11 <br />