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,x - '�.�'" �`;���`k?€3°�,:-r � . <br /> . . . .. . . - '� `�� <br /> , ���� �f ����� � <br /> x <br /> ,, z�� <br /> � <br /> �'�� fi 3�t��W�'a <br />� �� � ���I�eng Pe�r�i� Ap����a�iQr� �or li�aic��e�a�ee / Re�Qva�io� �� <br /> (winaov�s, doa�-s�, sidir�c�, re-roof, etc.) � <br />. �Maiiing Aadress: ' � <br />` ��w 0 PO Box 66 � Permit number. i � <br /> �(� � (� Crystal Bay, MN 55323-0066 Qate received: � <br /> ! �'�,< <br /> �„� l9"��'��-?'� �, 1 StreetAddress: Received b�y:� � � �� �� <br /> �`� '��'�'�� � 2750 Kelle Parkwa o , o. � <br /> �' t+,� o y Y Planrrevi.,v�fe.. � <br /> �� `���SHo�''� Orono, MN 55356 � � �� <br /> �' Total:Fee: � <br /> � Main: 952-249-4600 Fax. 952-249-4616 www.ci.orono.mn.us ` <br /> � <br />; t This appficaiion form must be compleied in full and all required inrormation must be submitted. � <br /> ' fncompfete appfications will be returnecl. (Please prrnt) "�� <br />� � G�NERAL INFORMATIOI�: . , �� 'i <br /> �� Job Site Address: .> � �C) '�i O�+ �l j �'16✓�� � �1' �>i�d�C� � <br />` a Will this be a Parade of Homes, Remodeiers Showcase Home or other Display Home? ❑ Yes ' No <br />: � !f yes, a special event permit rs required with Police Deparrment and City Council approval 60 days pnor fo the event. Shuttie bus serv�wil/be � <br /> = required unless appiicant demonstrates sufiicienf on-site parking rs available. Non-perrnrtted events wil/not be allowea. � <br /> CONTRACTOR/APPLICANT INFORMATIOI�: ' � <br /> Name: ✓�r��1�' L �`���� e_� � <br /> t.� <br /> State License # Expiraiion Qate: �; <br /> � <br /> Lead Certificafion Number: Expiration Qate: <br /> (for work on homes that were constructed prior to 1978 � <br /> � <br /> Phone: (office) (cell) � <br /> Maifing Address: Ciiy: ZIP: * <br /> Contact Person: Appficant is: Contractor / Homeowner (Circle One) <br /> Erriail and/or Fax: � <br /> � <br /> PROPERTY OWNER INFORMQTION: � <br /> ; Name: �����, � y`�'�Cd�u�C_� � <br />� ` Phone(day}: E,j Z_7/r, �-5•�3�i . <br />� Address: 3s jp r�o��-h �- � . <br /> 5 �G� � d✓' c�ty:U ��'�c,�� ziP:S�3 1! � <br /> Email and/or Fax � <br /> � <br /> r.•" ;»; <br /> � <br /> PRQJc�T IN��RM�TIOI�E: _' <br /> Type of Project: ' /any earth movement may require � <br /> ❑ Door(s) � MCWQ review& ermits: � <br /> ❑ Remodel ❑ Fire Qamage � P � <br /> i Minnehana Creek Watersned District(MCWD) <br /> ,E'J Re-roof, asphalt ❑ Repair ❑ Storm Qamage � 1E202 Minnetonka Bfvd '� <br /> ❑ Re-roof, cedar ❑ Restoration ❑V1,'ater Damage I Deephaven, MN 55391 <br /> ❑ Re-roof, other s e�i Phone: 952-47i-0590 <br /> ( p .,fy) ❑ Siding ❑ Other: (specify) i rax: 952-471-Oo82 <br /> ❑Window(s) I www.minnehahacreek.orq i � <br /> Ove�all Prolect Descr�ption: � <br /> Esfimated Construcfion Vafuafion of Project (exciuciing fand) $ �2�v�� <br /> �; APPLICART ACKNOWLE�G�M�t�T: <br /> • Agrees to provide all informaiion required or requested by the Building Depariment; � <br /> �. <br />, "' • Certiiies that the informafion suppiied is true and correct to the best of his/her knowfedge. The appficant recognizes that they <br /> are soleiy responsible for submitfing a compiete appiicacion being aware that upon tailure to do so, the staff has no alierna'tive � <br /> but to re}ect it untif it is complete; Fr,; <br /> • Some or all of the informafion that you are asked to provide on this appiication is classified by State law as either private or I <br /> confideniial. Private da;a is inforrriation which gene�alfy cannot be given to the pubfic but can be given to the subiect of the I <br /> data. Confideniia! daia is informafion which generally cannot be given to either the public or the subjec't 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 aqencies ! � <br /> reauired b law. If vou refuse to suppf tne inrormation, tne aoplication mav not be issued. ,� <br /> AppficanYs Sigrature: ,�� �� Qaie: � � <br /> �ast Updated: OP-09-201'f <br /> ,.. <br /> __ _ _ ,� <br />