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10/28/2015 12 : 57 T0: 19522494E16 FROM:6123544154 Page: 2
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<br /> �IT`��fl� C�I�C��C3
<br /> �111LDlldt� PERdU4IT F'PL1��71C�i�1
<br /> FtJR hIEW �TRUGTl1RES C��i /4DC�ITI��IS
<br /> ,� �� "�� M�ilingAddi�ss: Permit number: �LJ l �C�l � �
<br /> % �°,.�t�j PO Bax 66 ---------_.________;
<br /> /` � � Crystai Bay, M�1 55323-0066 Date received: �� �� ��� "�� �
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<br /> � Received b �
<br /> � � �� h r Street Address:� y -- --
<br /> '��.t � �� 2750 Kelley Parktvay Plan revievr fee:
<br /> ` `� c�rono, MN 55356
<br /> �``���s�{°�� 7otal Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 vvww.ci.�r�r�a.m�.�s
<br /> __...______ ----- -= _- -- - / $'�, �
<br /> This application form must be compieted in full and ail required information must be submitte
<br /> Incc�rrtpiete�pplications wi11 be returned. (Pleas�pnnt)
<br /> �E�1��tAL fN�t�RMATIt7N; ;
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<br /> Job Site Address: ""
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<br /> Will this be a I'arade of Homes, Remod rs�hawcase Nt�me or other Display Home? ❑ Yes 'L�° No
<br /> K yas, a speera/event perrnit rs required U�ith Police l7epartmeni and City Council�,pprova160 days prior to tl�e eveqt. Shuttle bus servrce wilt be
<br /> reqi�ired unless apnlicant demonstra?es suffrcrent an-site parking is available. Narr-permiftEd events�n�iil nof be adowed.
<br /> �CtN7RAC70R l APP CANT 1N�OR A710N: _:
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<br /> St�te License# �� r c'�" i '� Ex iration Date` ''
<br /> _ �.tt- ;� 5 c��f`� _ _...____ �' �"_�_ �.�>��`"
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<br /> Phone: cell -�=� ' �_'j-�'�� (office �`�� "• i=' � � � �, _..
<br /> Mailing Address: � .,.� `���r',���-£..' i�vz" 1�i_._`�.���' City;_ � `` .t,'t���__ ZIP��_�_..��_�
<br /> Cnn�a�t Person: --���k����� ������-�.�,�_ __�Applicant is: tr cfor I Homeowner �c�r���o�,e�
<br /> Email andlor Fax: �-`s�i������'' � �� �.r�� ��.�}�G�C�;�z��tt'?t f��' ��m�:�.
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<br /> PR�PERTY OWNEFy,lAJFqi�MA71C3h1;
<br /> Name: ���{� �i'1 �.,t?�`���r��. _.._ .... _.___.. . _ ___ _ _..___ _- -_._.--
<br /> Phone (day): _��I �.,.�. _.�-1'��� t,l%�fiS� / / ,�� C�.'C'" -� �'
<br /> Rddress: __:���i(�_._ ...__l��(��-�._vv C.�,?G: t..�.. ���w�?._._._� ..... - - - — �� —� --._.�.�,J�_,u�-s...�'�.G%--
<br /> � t' Gity_ly.�t�(,,�l1{j---_ LIP �
<br /> E,nail and/or Fax
<br /> ,��tChlil"�C71 �NGINE�R iNF�Rh11Ai"#UN:
<br /> N�me:
<br /> Phon�(day}: �� �
<br /> Addt'ess: � �.— �_ City� ZIP: �----�
<br /> �rnail andlor Fax ~�
<br /> � �����r-�t� �',�t:.`���`1� C�ft���= I (� �'�C'-t�t,t�f � ti•e1r`C.��-�. � G��C�t�'�✓?{—�`����:.a._.i ������
<br /> F��2t�J�C7 IN��RMATiON: ��escriptio�� ro�ect: ` ����' ` ��,'�r���C�-�
<br /> , 1. Type of Project 2. Propased Us--�e-����� 3.Structure Type d. Sewage bisposal& �
<br /> i �� ^ �r Water Se�PP'�Y
<br /> i
<br /> f ❑ New Consfruction ' "ngle Famiiy wifh �;�-tesitlence i
<br /> � [] Addition attached garage �; � Garage!Accessory Bldg. ❑ Pubiic Sewer �
<br /> ; (��1�eessary Building � ❑ Single�amily with '�� � Deck �
<br /> i ❑,�,�elor,ation ��, ,. �� detached garage ' �J OfficelCommercial ❑ Private aewer '
<br /> �}'`Other: (sp�cify) �-� ` �� � ❑ tvlultiple Family 1�ondo '', ❑ Waref�ouse
<br /> � �• ❑ Pubiic ❑ Storaye ❑ Public Water �
<br /> ""Any earth r��ovesnent may also require � ❑ C�mm�rciaf ; ❑ Oth�r(specify} �
<br /> 14hCWD review&permits. ; ❑ I�dustrial � ❑ Privaie Weii !
<br /> Minnehaha Creek Watershed C(stricf(MLN1D) 1 ❑ Othei: (SpeCify) � !
<br /> � 18202 tvtrnneto��ka Slvd � ! '
<br /> � Deephaven,MN 55391 �� `� � '
<br /> {I Fhone: 952-4?1-0590 �
<br /> i� Fax: 952-471-0682
<br /> �_��N�v mi�Pei,aFacreek or�
<br /> : . —T_ ..__..__..._ ._.. __ ,. __.._____ ___—__..
<br /> ��,�-�;- ----
<br /> Estim�ted Construction Valuation (excluciing land} $ �'Z��� a,y�r
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