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""�,�: �'r;y�sc�y%5l,��.- � <br /> '>�� y` h'.� <br /> � �t�� �f ��c��c� ;` � �` <br /> . � ��� <br /> ��Gi���t� f��r��� �.��6�c����� �c��- �a��a�a�a��� / �er�c������� � ��'� <br /> ;��� � ' �v�i�ciQ���, �iaa�-�, siai�g, �-�-ra�f, ��c.) � <br /> � �.. <br /> Mailin Address: D , � � <br /> � ����� PO Box oo � Perm'it=number: p7 l l� '; <br /> "� /(� � �� Crystal Bay, MN 55323-DOo6 � Qate received; - � `/2--; <br /> , <br />.f; i 3 t,,� <br /> �a 1� « �'` ,� Srreet pddress: RecAiv�d b��: <br /> � <br /> .`l' \� �l�" �z...� � Q <br /> i, ��cn � ��j'�, � 2750 Kell.,y Parkway <br /> .��"�''\�rr,-'`�+�-, Plan review fee: <br /> `��Esxoy"� Orono, MN 55356 <br /> To,a�.Fee: J�J� �� � <br /> Main: �52-249-4000 Fax: °52-249-4010 www.ci.orono.mn.us _ � <br /> This appficaiion Torm must be completed ir full and all required inrormaiion must be submitted. �� <br /> incompfete appiicaiion will be returned. (Please prrnt) � <br /> uEN=RAL INFORMATIOn: /� � '' <br /> Job Site Acidress: �� ! � <br /> Wil! tnis be a Parade ot Homes, Remode�ers� Showcasa Home or other Disp�ay Fiome? U Yes i � �fo <br /> !f yes, a special event permif is required wifh Poiice Departmenf and Cify Counci!approva!6D days pnor to the event. Snuttie bus s rv e wil!be <br /> J required unlsss appficant aemonstrates suffic�ent on-site parking is available. Nor,-Qermitted events wif/not be aliowed. <br /> 1� �-, <br /> a.�� <br />'�, COIVTRAC�'OR!�PPLICANT INrOP.M�}TIO�t: � <br />�,�: �vame: '/ �- �`� o�J1 � �I� U� 27���-- ��� � <br />�;� � <br />� ' State License# C �xpiraiion Cate: <br /> t�, <br /> Lead Certificafion Number. Expiration Qate: <br />`.�' (Tor work on f�omes thaf were constructe�'prior ro 1978 <br /> � <br />` j Phone: (office) (cell) <br /> � Maiiing Address: <br />� p City: ZIP: <br /> Contact Person: Appiicant is: Contractor / Homeowner (Circfe One) <br /> Email and/or Fax; <br /> PRO?�RTY OWNER IN�ORMATION: <br /> Name: � � �,�S <br /> Phone(�ay): �S'�— �j % — y . <br /> Address: 1.3�T� 1�G_of� �2. City:ii%�-�-��zal� z�p's S-3�� <br />;_�- Email and/or Fax -'�� ' . <br /> .�.�. PRQJ�,CT IN�ORMf�,�IOR�: <br /> ,� Type of Project, ' Any eartn movement rra}�require `� <br /> I Door(s) � ❑ Remodel ❑ =ire Camage MCWD review&permits: I � <br /> Ninnehaha Creek Waiershed District(MCWD) � <br /> ' R e-r o o f, a s ha l t g i 1 E202 Minnetonka Blvo <br /> ' 1 P ❑ Repair ❑ Storm Dama e i <br /> � ❑ Re-roof, ceclar � Deeohaven, Mh' ��391 <br /> � ❑ Restorafion ❑ V�ater Gamage <br /> 1 Phone: 952-471-Q590 <br /> ...1 ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Far,: 952-471-0082 <br /> "� I ❑Window(s) www.minnehahacreek orq <br /> i � <br /> .-� Overall Projec� ��scripfiaR: � <br /> =siirrzated Construciion �.°afuaiion of Frojecf (�xciucfing ;and) � �� <br /> �PPLl�AI�T �CF�f�JVIlL=D�=M�t��: � <br /> � Agrees to provide all inrormaiior required or requested by fne Building Department; I � <br /> F • �eriifies trat the informafion suppiied is true and corre�t to tne best of his/her knowledge. The appficant recognizes tra� tney I � <br /> are sofely responsible for submit'ting a compiete appiication being aware that uoon �ailur�to do so, tne s'taff ras no aliernaTive I ,�� <br /> but to reje�t it until it is compiete; <br /> � Some or al! o` tne informafion that you are asked to provide on tnis aopiication is ciassified by State iaw as eitner private or j �� <br /> ,, confidentiaL ?rivate clata is inrormation wnich gene;aliy cannot be given to the pubiic but can be qiven to the subject of ihe I Y <br /> aata. Confidential da;2 is information wnich generally cannot be qiven to eitner tne pubiic or tne subiect o` tne data. Our , s <br /> � i purpose and intenoed use of this information is tc annualfv update our records and records of otner governmen,al aqencies <br /> � � reauired b��law. If vou refuse to sup�iv tne inr rmaiion.the aopfication mav not be issued. <br /> AppltcanYs Sigrature: ���—� ���. _ Date: -� <br /> � <br /> '_ast Updated: 08-09-2U11 .,��� <br /> i <br /> �;� <br /> ,.s .. �� _a.. _ _s_ _ � .. _ _ �, _ _. �_�r _ <br />