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�-���� �*<� ri �§ }, r �z. <br /> ._ _ _. {f <br /> . ���� �� Q��-c��c� �_ � � ,; <br /> ��6����g ����E� �a.�a�������c�r� ��r f�a���ar��r��� E �er���a���€� <br /> �VIPlG1C�C��l1.°�, �C10€"�, Sl�if'1�, C�-Caaf, ��C.� � <br /> � M,aiiing Aaaress: i Permit number. � <br /> %/���� PO Bo>:oo I � ,; <br /> �� � Crystai Bay, MN 55323-0066 � Dat�received: � <br /> � <br /> ��\� �" ��'` � � Sireef Address: Received n,y: � <br /> � '��"b'� � 2750 Kelie Parkwa <br /> �`����r�4 G Orono MNy55356 y Plan:review tee: � <br /> �Esa3o � <br /> To:al �e�; �: <br /> Main: 952-249-4000 �ax: 952-249-4010 wwv,�.ci.orono.mn.us � � <br /> This application Torm must be compi�'teo in Tull and all required informaiion must be submitted. �?u <br /> incompiete appficafions will be returnecl. (Please prrnt) s�'' <br /> u��I�P.A� INr=ORMATtOR: � <br /> 3ob Site Address: 3 U�Z O �/��.;� ��c�� ��/ r/� � <br /> Wiil tnis be a Pa�ade of Homes, Remo efers Snowcase Home or other E3�s ta Fiome? � �' <br /> P Y L I Y.,s ❑ t�o #i <br /> If yes, a specra/event permit is repuired with Police Depar[menf and City Council ap,proval 60 days prior to the evenf. Snuttie bus servrce wil/be <br /> required unless applrant demonstrates sufiicient on-site parking rs available. Non-permitted events wil/not be allowed. '� <br /> �� <br /> _ CONTRACTOR/APPLICA�fT INrORMATl01�: t � <br /> � fvame: �`� �f�2 G�.c����Yv G"I i E�CJ <br /> State License # �G / �,5�� �xpiration Cate: y � <br /> Lead Certir'ication Number. 1������.- Expirafion Cate: i51�a — � <br /> /S � <br /> (Tor work on homes that were constructec'prior to 1978 � <br /> Phone: _ •'l/ .'� �y�79 -1� �D d (office) (c�ll) � <br /> Maifing Address: ' `�--- �- �' / � Cijy: � � ZIP: - � <br /> Contact Person: � Appiicant is� r / Homeowner �Circle One) �� <br /> - Email and/or Fax: .-�� <br /> � <br /> PROPcRTY OWNER INFORM!{TIOt�t: � <br /> � <br /> ame: ,�i-C1c�/SDiU rGE-� � <br /> Phone (�ay): 95��D�l��.�lv,y • �;� <br /> Address: �—/�D 10 /fo�2�,' l�v�c� 1��9 � Cii`/�l/ ZfP� � <br /> Email and/or Fax ' � `�� ,f`�/�z� �� � �� �- <br /> '� <br /> '����, <br /> PR�J:GT IN=OrZMe�e�ION'; � <br /> Type of Project: i ! Any earth movement m�ay require � <br /> I <br /> ❑ Door(s) ❑ Remodel ! ❑ Fire Camage MCWQ review&permits: � <br /> � � Ninnehana Creek Watershed District(MCWD) �� <br /> �'Re-roof, asphatf ❑ Repair ❑ Storm Damage 16202 Ninnetoni;a Bfvd <br /> ❑ Re-roof, ce�ar ❑ Restoration ❑V�'aier Gamage � Deephaven, MN 55391 <br /> Pnone: 952-471-Q590 t* <br /> ❑ Re-roof, other(speci"ry) ❑ Siding ❑ Other: (specify} Fax: 952-471-Oo82 '� <br /> ❑Window(s) � � www.minnehahacreek.orq <br /> I :,, <br /> Overall Froject �escripfioR: ',� <br /> =siirr,atecE Cor.s"truction �.°afuation o` ?r�ject (exciuciing �and) � � Cj�6 , v a Z � � � <br /> APP�.I��t�T �,CKiVOVIlL�D:��M��€T: � <br /> � /-�grees to provide all informafion required or requested by the Building Depariment; � <br /> � Certifies that the informaiion suppiied is true and corre�t to the best o� nis/ner knowleage. The applicant recognizes tha: tney : � � <br /> are sofely responsible for submitting a complete appiicaiion being aware tnat upon �ailure to do so, tne staff has no altemaiive � <br /> but io reject it until it is compfete; <br /> � �i � <br /> I� � Some or all of the informafion that you are asked to provide on tnis appiication is ciassified by S�ate iaw as eitner privaiG or / <br /> K <br /> confidentiaf. Private data is inTorma'tion wnich gene;aliy cannot be given to the pubiic but can be qiven to the subject of fhe '" <br /> � da:a. Confidenfia! data is informatior whicn gene�aliy cannot be iven to eitner the � + { � �� <br /> 9� pubii� o� th., subiec, o� tn„ cata. Gur ,�: <br /> I purpose and intended use of tnis informafion is to annually update our recores and re�ords of otner governmen,al agencies °�' <br /> required b��faw If vou r�rus�to suppfv tne iniorma"tion tne aopfi�atlon mav no`b� issu�d �x <br /> i <br /> ApplicanYs Signaiure: � G.�i�� Qato � '� � <br /> �s:UpdateC: 08-6S-2D1 i `� <br /> �, <br /> �� <br /> , <br /> �, _ , . ,�i <br />