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�; � i�,Z�, �� � . <br /> ���� �f ����a <br /> . 8��6�ing Pe�m�� A�ap6i�a�iQr� �ar t�adr��er�a�ce / F�e�Q�a�ica� �. 2� �* <br />�, (winaovNs, d�ors, siding, r�-ro�f, e�c.) �D <br /> Mailrng Address: _� <br /> �� PO Box 66 ' Permit number. a�0(o� ��Z7� <br /> �� �,, <br /> 0\ Crystai Bay, MN 55323-0066 Date received: 1 Z - Z I - �� <br /> �,a � '�, �, � Street Address: Receivetl by: � ` <br /> ���c, d'�� � 2750 Kelle Parkwa � �.. <br /> o Y Y Plan reviewfee: (p7. l � <br /> ��'�,�rEs'�o4"� Orono, MN 55356 020�o� �� l a(p G1 ' �' <br /> Total Fee: `' <br /> Main: 952-249-4600 Fax: 952-249-4016 www.ci.orono.mn.us �' <br /> This applicaiion form must be completed in full and all required information must be submitted. � <br /> incompiete appfica4ions will be returnecl. (Please print) �° <br /> GEN�RA� INFORMATIOf�: �, � <br /> r Job Site Address: ` ; �j ��-( � -��� � �� � <br /> �` Will this be a Parade of Homes, Remodeiers Showcase Home or other Display Home? U Yes No `�' <br /> _ ❑ ����� <br /> If yes, a spec�al event permif is required with Po(ice Department and City Council approval 60 days pnor to the event. Snuttie bus service wil!be � <br /> s� ., <br /> . required unless app/icanf demonstrates sufr`rcienf on-site parking is available. Non-permitted events wil/not be allowed. "� <br /> 4ajW <br /> t�' i� <br /> CONTRACTOR/APP CANT INFORMATIOI�: <br />� "° Name: ���/� � ���f�'���'�� � <br /> State License# ,t� �� <br /> '. �>4 �xpiration Qate: ,� <br />�' ' Lead CertiTication Number: Expiration Date: � <br />�� (for work on homes fhat were constructed prior fo 1978 � <br /> YeY: <br />�� Phone: %a--�c�-O-__ �}� �� (ofiice) (cell) � <br /> N'�aifing Address: �E..� � j� �Z City: �; ZJ�J� ZIP: _-� '� � <br /> , Contact Person: � �J� � ' }��.,�ppficant is: Contractor�,�rfieowner �Circfe One) � <br /> � Email and/or Fax: '� _-c' r- � <br /> t� <br /> PROPERTY OWN�R INFORMATION: <br /> Name: �.. . ,�1.'�k l f�'`'�"(...i�� -./ _� <br /> �.--'� <br /> Phone da - . �� <br /> � Y)� f5:�-��� " y , ) � � <br /> Address: l�S ���-T�-�- �}-K�y''� '�!L CitY� l �''D�� � ZIP: iS �bT :�� <br /> Email and/or Fax �C'�-�(�1..�� S )7 ;�,: <br /> , � <br />� PROJ`C� INFORMATIOI�: ��� <br /> �; <br /> Type of Project: I I i �� <br /> Any earth movement rray require �° <br /> Door(s) �odel � g MCWD review&permits: � <br /> � ❑ Fire Qama e <br /> I Ninnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvo � � <br /> ❑ Re-roof, cec3ar ❑ Restoration ❑Water Damage Deephaven, MN 55391 � <br /> � Phone: 952-471-Q590 � <br /> g � ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) � Far.: 952-471-Oo82 x� <br /> www.minnehahacreek.orq ``°' <br /> �indow(s) � ,:� <br /> ..:; <br /> Overall Project Des�riptioR: ��:' <br /> �$; <br /> _ Esfirrzated Construcfion �lafuaiion of Project (excfuciing fand) � — `��, <br /> �r <br /> APPLICAMT ACKNOWLCD�`McI�E�': �; <br /> • Aarees to provide all informafion required or requested by the Building Department; I � <br /> • Certifies that the information supplied is true and correct to the best o� his/her knowledge. Tne applicant recognizes that they � � <br /> are sofely responsible for submitfing a complete appfication being aware that upon failure to do so, tne staff has no alternative ,� <br /> but to reject it until it is�ompfete; <br /> • Some or all of the inrormafion that you are asked to provide on this application is classified by State law as either private or �'�? <br /> confidential. Private data is informaiion wnich generaliy cannot be given to the pubfic but can be given to the subiect of the �� <br /> data. Confidenfial data is information which generalfy cannof be giver to eitner the pubiic or the subiec't of tne data. Our �� <br /> purpose and intended use of this information is to annually update our recoras and records of other qovernmen,al agencies I ,�� <br /> reauired by law. If ou refuse to suppfv tne information the aopfication rrav not be issu�d <br /> � <br /> / �: <br /> AppficanYs Signature: _.,�/ Daie: f���"� p� �`�; <br /> Last Updated: OP-a9-2011 �� <br /> , <br />� l _ ..�:', <br />