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<br /> B�`i�ir�g Pe�-r�it A►ppf��a�i�� �ar NEaic��e�a�ce l �e�Q�sa�ic�� � � -�
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<br /> (windov�►s, doo€-s, siding, �e-�o�f, e�c.� ,a
<br /> Maiiing Aaaress: � �a_� ,��,
<br /> �� PO Box 66 Permit number.
<br /> /(� ��` Crystai Bay, MN 5�323-0066 Qate received: % '/� / � ; �
<br /> 1 � , �,,
<br /> ��� ' � a. Street Address: Received by:
<br /> � � ' fJ� :
<br /> \�r '� �'�' � 2750 Kelle Parkwa
<br /> c� �,� � Y Y Pkan:review fee: � (' l'�'�ix c f� c�
<br /> �t`�.kE�SH� Orono, MN 55356
<br /> Total Fee: /
<br /> Main: 952-249-4000 Fax: 952-249-4616 www.ci.orono.mn.us / � �� � . �� j r, ' s�-�
<br /> This appiicaiion form must be compfeted in full and all required informafion must be submitted. r-�y-iZ
<br /> incompfete appficafions will be returnect. (Please print)
<br /> GENERAL INFORMATIOf�: G ,y
<br /> Job Site Address: � (o bg IJ• T �'t'R.� �i�- �-o�� L�t�E M r✓- a;_,
<br /> , �-�
<br /> Will this be a Parade of Homes, Remocfefer� Showcase Home or other Disp{ay Home? ❑ Yes [�',f�o r�
<br /> lfyes, a specia/event permif rs required wifh Po(ice Deparrmenf and City Counci!approval 60 days prior to the event. Shuttle bus service wil!be �
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> �
<br /> CONTRAC'i"OR/APPUCANT INrORM,4T101�: , �
<br /> Name: �"LiT� 2�MoA6'c.��/� s�x.v+c�s /N'C. �
<br /> � S.ate License # � �3 g�y y Expiraiion Qate: �
<br />� . 3- 31- zo�y
<br /> Lead Certificafion Number: 8��,,,�- /9$y Expiration Cate:
<br />�`- (for work on homes that were constructed prior fo 1978
<br />��� Phone: (ofiice) ��{ 6/s. -2g2-glo8(cell)
<br /> Maifing Address: /�061 ��'AT K,nio} �Q�, City: ,�.,c,,,,,,�ra�r r►�✓Z�P� $g'o2y �
<br /> 4 f Contact Person: ,��,,�,�,/ �siS�.F Appficant is: Contractor / Homeowner (Ciroie One) ��
<br /> Email and/or Fax: Q � 3Y66 '��'
<br /> �L+YI1/ /�&i SCf� �I �'hML. � C o M Cc'LL.— 6/2� 2'�2—
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<br /> � PROPERTY OWNER INFORMATION: �
<br />��
<br />��:' Name: f�N?a/N' E /gC2�'DE�2.5 MbN /`'�ouT�'a�rjeK/E� '�
<br /> �;. .�
<br />��` Phone(day): M� � 5/2-65'b- SD 7 .
<br />,_r�' Address: f 6 69 /✓� F,�-�,y� ,1�� City:�„„�j G�-,rF ZIP: �
<br />� Email and/or Fax �.e n �o�,e.re,,� � � , Go..� ��
<br /> ��
<br /> PROJ�CT INFORMa4TlOt�: �
<br />�" Type of Project: ! ,4ny earth movement rrzay require �
<br />� �' ❑ Door(s) [Jf Remodel ❑ Fire Qamage MCWD review&permits: �
<br /> �,� � Ninnehaha Creek Watershed Disfrict(MCWD) -�
<br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage � 18202 Minnetonka Blvd '�
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 '
<br /> Phone: 952-471-Q590 �
<br /> I ❑ Re-roof, other(specify) ❑ Siding ❑ Other. (soecify) Far.: 952-471-0682 ��
<br /> I [�Wind w(s) • � www.rninnehahacreek.orq
<br /> � �
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<br /> Overall Project Descripfiors: K�7rN�eN ��i��nr!'r J�oo� fl.d+lo-+�� "`
<br /> �sfimated Construcfion Valuafion of Project (exciuding fand) $ (,2 so o "i �
<br /> �;r;
<br /> APP�IC,�►NkT ACKNOWLE��EMcf��": �'�
<br /> �
<br /> • Agrees to provide all information required or requested by the Building Department; t
<br /> • Certifies that the information supplied is true and correct to the besf of his/her knowfedge. The applicant recognizes that they �
<br /> are solely responsible for submitting a compiete appficaiion being aware that upon Tailure to do so, the staff has no alternative �ql
<br /> but to reject it until it is complete; ,,�
<br /> • Some or all of the informafion tF�at you are asked to provide on this application is cfassified by State law as eitner private or i �
<br /> confideniial. Private da;a is inforrrzation which gene;alfy cannot be given to the pub(ic but can be given to tne subject of the �'
<br /> data. Confidenfial data is informafion which generally cannot be given to either tne oubiic or the subject of tne da,a. Our ��
<br /> purpose and intended use of this information is to annualfy update our records and records of other govemmen,al agencies �
<br /> reauired bv law. If ou refuse to suppf the intorrriation, tne a�piica'tion mav not be issued. �j
<br /> ' �6/�� �e17£Ll��r �
<br />�"� AppficanYs Signature: Se�y�,ti �,/�� Date: Q-ll-l�—
<br /> �
<br /> '_ast Updated: 0�-OS-20^'
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