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� ' ' � ' '''� �_� .� '��:�� ���
<br /> � ���� a�f C��o��� �
<br />'� 't��a`��ir�g Pe���f App�i�a�io� for li�air��e�a�ce l �enQva�ia�
<br /> ,I •
<br /> � (windov�►s, doa�-s, siding, re-roof, e�c.) ,
<br />, � �
<br />;4, Maifing Address . �
<br />�.E /� PO Box o6 i Permit number. �-O (�-(TU 9 I �:
<br /> C stal Ba MN 55323-0066 Date received: �,
<br /> �� �',.�:., � �' y' c1 / 3 -/ �
<br />, �•.
<br /> ��`� I� � � �, � Streef Address: Received by �
<br /> `�' � ��'�' ti ' 2750 Ke(le Parkwa � � � ��
<br /> \;�'��"i�R�' ° Y Y Plani;reviewfen,
<br /> ;�� gESHo�''� Orono, MN 55356 �
<br /> Y{ Total Fee: � �'1 ,� - � a �;
<br />�� Main: �52-249-4000 Fax: 952-249-4616 www.ci.orono.mn.us `�
<br /> This appiication form must be completed in full and all required information must be submitted. �
<br /> incompfete appficafions will be returnecl. (Please print) ;�
<br /> y' � GENERAL INFORI1rATlOf�: ��-
<br /> Job Site Address:
<br /> 1 /S I��.v� 1.`���. �'`� �a , ;�IUI� �s��� � ��
<br /> Will thEs be a Parade of Homes, Remodeiers Showcase Home or other Display Nome? ❑ Yes P�o ��
<br /> lf yes, a spec�al event permit rs required with Police Departmenf and City Counci,'approval 60 days prior to the event. Shuttre bus ae�e wi(l be �"';
<br /> required unless appficant demonstrates sufiicient on-site parking rs available. Non-permitted events wil/not be allowea'.
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<br /> I �
<br /> ! CONTRACTOR/APPLICANT INFORMA'�101�:
<br /> r�<1 N a m e: f/�. � G-Gr�=c••-1 L� �— �
<br /> :�� State License # �� ��,_� ��S � Expiration Date: 3 � :�
<br /> � Lead Certification Number. Expiration Qate: ,�
<br /> f:� (for work on homes thaf were consfructed rior fo 1978 � ��
<br /> � Phone: �O�Z' S'�a/-L1�� � (office) ��o���
<br /> Maiiing Address: � ���-�� City: � ZIP� � ;_
<br /> Contact Person: )�,,,,«,,�y� App(icant is: ontractor / Homeowner �Circ{e One) �
<br /> Emai! and/or Fax: bj-�1h,, 1����..� � g��7--L � C�� 5,=
<br /> �
<br /> � ��
<br /> �'=; PROPERTY OWN INFORMATIOI�:
<br />;�; Name: l� �
<br /> a..
<br /> rZ c� �
<br /> � . Phone(day): �PIZ� (py5�-(ol� � ' ��
<br />�'> Address: i�/� I-�G.�� 1�l''�✓� City:Q�,,t� ZIP' �� F��
<br /> Email and/or Fax `
<br /> �
<br /> ��
<br />°- PROJcCT INFORM�eT101�:
<br /> Type of Project: qny earth movement rrsay require �
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Camage I MCWD review&permits: !3`
<br /> Minnehana Creek Watershed District(MCWD) �
<br />,�"�� Re-roof, asphalf ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd � �'
<br /> ❑ Re-roof, cedar ❑ Restorafion Deephaven, MN 55391 �
<br /> ❑Water Damage �;�
<br /> Pnone: 952-471-Q590 �
<br /> �. ❑ Re-roaf, other(specify) ❑ Siding ❑ Other: (specify) Far.: 952-471-OoS2 �`-
<br /> �,,
<br /> � ❑Window(s) � www.rninnehahacreek.orq � �
<br /> �` � �
<br /> Overall Project Description: � ��+:
<br /> ✓vt '� T s :-��L�S �r�c-fa C( ►�eGh I 2�n L� -�-r� �/a�'� �r�
<br /> Esfimate�t Construction Vafuation of Prolect (exciuding fand) � ����j ��
<br /> � �;;A
<br /> ��
<br /> APPLI�AI�4T ACKNOWLED�EMcf�(T: ;��
<br /> �;.
<br />�r:- • Agrees to provide all inrorrnation required or requested by the Building Department;
<br /> • Certir'ies that the informaiion supoGed is irue and correct to the best of his/her knowledge. The appficant recognizes that they �
<br /> �;
<br /> are sofely responsible for submitting a compfete appiicaiion being aware that upon failure to do so, the staff has no aliernative
<br /> �N;
<br /> but to reject it unfil it is complete;
<br /> I • Some or all of tne information that you are asked to provide on this application is ciassified by S,a'te law as eitner private or ���
<br /> � coniideniial. Private da,a is information which gene;alfy cannot be given to the pubfic but can be given to the subiect of tne
<br /> ! da,a. Confidenfial data is informatior which generalfy cannot be given to either the pubfic or the subjec't oT tne data. Our
<br /> Ipurpose and intended use of this information is to annualiy update our records and records of other qovernmen;al aqencies
<br /> �
<br /> re uired by law. If vou refuse to suppiy tne inrormation tne appfication mav not bP ICSL�Ad I t�
<br /> ApplicanYs Sigrature: �� _ paLo: I� � f Z ,',`
<br /> _J
<br /> �zst Updated: OP,-09-2D11
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