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<br /> ��eldinc� Perr�it i4pplication for fVl�intenance / Replacement / Remoc�el — Residential �iVLY
<br /> ` (i.�e �i�e�'���s ��a���y �'s�'e����y �e���a��, ��c. � �� ���l��TIJRA,� ��P��R����)
<br /> A , Mailing Address: O �7_�I�
<br /> ��f V� PO Box 66 Permit number: �l/
<br /> Crystal Bay, MN 55323-0066 Date received: —.Z/—�
<br /> � �
<br /> Street Address: Received by:
<br /> y�, G� 2750 Kelley Parkway Plan review fe :
<br /> Orono, MN 55356 �
<br /> lqKESHO�� f � /� �,�/"
<br /> Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 �v,��-�,�:.ci.000no.mr�.us
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORI1ApeT10N:
<br /> Job Site Address: .'�'�s'" ,�r=sT� /�'o��i ��►-�
<br /> Vllill this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes � I�o
<br /> lf yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR I APPLICANT INFORMATION:
<br /> Name: �.rr.�,�� y���.,,,-c L�.�T��- � -�-i ,8. Li«���,�Y�s;v
<br /> State License# ,���� /G y� Expiration Date: 3 3, i8
<br /> Lead Certification Number: y�„fi � 70�� � Expiration Date: �
<br /> / �9 �Cl
<br /> (for work on homes fhat were constructed prior fo 1978
<br /> Phone: (cell) �Gi�) G�� ._ � �, 6 (office) �7 d'3 � %7� —��o/
<br /> Mailing Address: �>�o y SS City: �r,.Yn/ Z�P: SSyS'�
<br /> Contact Person: ,��,�r �, G��r fiti*y-�rr� Applicant is: Con ractor / Homeowner (Circle One)
<br /> Email and/or Fax: ,�c,��f,y�.s�����v��,,,..tt�`���,,.�<<,,.:..,�:�� �d.�
<br /> PROPERTY OIlVNER IfVFORMATION:
<br /> Name: �s«�wr { ,�i,n.�:�a� �'.,vf.�-,o�lL
<br /> Phone (day): �j'S�f yg S.--g�� ci
<br /> Address: /yo s— /1���r� �,`;....-i iPan-r., City: /yt�,,.-A ZIP: J'"S"3dy
<br /> Email and/or Fax:
<br /> PROJECT INFORMATION: Overall project description:
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits:
<br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> ❑ Re-roof,cedar 15320 Minnetonka Blvd
<br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345
<br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590
<br /> (./�3� Fax: 952-471-0682
<br /> Window(s) ,f�/f —S'ir�r� SiZf nE���� W�Nw.minnehahacreek.orq
<br /> Estimated Construction Valuation of Project (excluding land) $ G�G�a, oa
<br /> <iPPLICANT' ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department;
<br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are
<br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to
<br /> reject it until it is complete;
<br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or
<br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data.
<br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and
<br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If
<br /> ou refuse to su I the information, the a lication ma not be issued.
<br /> Applicant's Signature: �,,� /� �`' Date: �/�� / �7
<br /> Owner's Signature: Date:
<br /> Last Updated:January 2016
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