|
Mar 29,2018 05:06 PM To:19522494616 Page 2/2 From:Go Permits LLC Fax:8604718765
<br /> ` { r
<br /> CC�y' �f C�PQt1�
<br /> Buiid€ng Permit Appt�cation far Maintenance J Replacement/Remtade!-R�i�_+�i���7NLY
<br /> (�:e,wi�c€ows,doat�,sicling,re-maf,�tc.�-EHCI S�1�C'�t1F�.���ANt��pN�}
<br /> `��� MerJrR'p BOx 66. Peftlfat rWmb9r Q'.�
<br /> /� .._.___. _�.._..,...- ..._. �--/
<br /> � ``✓ � CryrstalBaY.luAN 5rai�-Ut1�6 C7�3L�r�Ceivad:
<br /> 4 Sfreei Add+'ess_ F+'eceived b�+;
<br /> 1 f �'� 2754 Kelley Parkw-ey Plan reuiew�. -- .
<br /> . cu ;
<br /> � `�t �,LR•` Orono.Ma+15535�6 --�. _.. ._... �
<br /> ���s sec�a/`
<br /> ����� S 53.93
<br /> AAain: 952-24g-0640 Fax; 952-249�1616 �.,u�r r cxenc�Enn��
<br /> _..�........._...._........._..........__.._.___._._...._,_..._._....................__..._.............__.,,..._ .__.w,::`.�_._,.w.:Tq._._�......._. .....,_._.....�.,.....�._.. _w:.._,.w�....,,........_----.__..._..
<br /> Thas app�'epdon fome mus#be completed�n ful�arpd aR re u�red imfarr�al�or�must be submitted.
<br /> Inpp�nplPte appGeations w�l De reburrted (Plea�e prFnt)
<br /> G�hIERAL INFORAAATIOifi:
<br /> .fob 5a:te,4�d�s�: �..��1_���.._ '.�.«��
<br /> ........, . ,............ ... ...._._r..,.... .. ,..,
<br /> 4Vi1f this Ge a Parade of Homes,Remodste�rs 5how�ase!#arne ar vther aisplay Hor�7 Ye� o
<br /> nres.a s��ar e�u a��s rew,wen'w�,�ce�u�d c;cy eaundr s��r sr1 asys�rorco e�e�nc snesrre w,s se.���rr be
<br /> r�euiless appfecaa�demnnsFratss s�irreM aua•s�e parkit�g is auae�aBJ`e. AIo��Remiulted ewere�s wi0 r�bs aQow�d.
<br /> con�r�ac�c�r r�Ruc�r N��a�,ar�oa:
<br /> 1- / ,p �
<br /> M16a3m¢� .,1.:?�YY]�...,:Y.�'� �c�t} _-- ---
<br /> SQate Lic�se# --.---_._.._...�.__ ...----
<br /> �:��.�� _ _..2 _ __ _ �icpirateon.E�afe: �/ 1�
<br /> Lead Certification Plurttber ��._.�!.�jrZ.:�`.1�. __ _ F.acp9r8tiOn Date: �. ��
<br /> � ..._ � _...
<br /> (Yor ww�r an homcs il�t wvere canstructe�Fl�rror to 19a8
<br /> Pl1of1@: ���._�.�'��'�1-a�"���a� �'�ffiC@}
<br /> _._..._ _.. _.�. _..............._._.__.._......_........
<br /> fwtaiGng Address: a�.l� �?$.� ��-l�d__ City: - r¢Q�_Zli':_��_
<br /> Contact Pe�son_ fkppliC�nt�s. r�traCk�Qr Homeownea' tcrr�w ona>
<br /> t�:���G?!��'L�2'j(�- __........._ ._. ...._ _
<br /> Emaa an�'Qr Fax: ��.�t�`T�����e�_4�2_�.....�-�t�_`���:�7L�—_..___ _..__..
<br /> ,/
<br /> PROP�R7Y QWNER INFQRI�A�3N:
<br /> tVam�: r����i ,..
<br /> ,... ,, ,.. ------....__._....._..___�..._..__ ---�_ ... _.._
<br /> Phone(dayj; �r2.��..".�.�rt,:�'�.- �''�.e��
<br /> Ad��55: '� � �11�'2,C4.�e ZIP:.`�'�
<br /> .e�.d.��_s.�l�f�h1....��.._.... _
<br /> Em�i1�ndlor F�c_
<br /> :PRQ1�L'T iNFQRMATIt1N _Qveral��ra�e�ct de�xipti,oa,:
<br /> Typc 0�€PtdJ4cL : : � Any earth movemen€may alsa raquitia
<br /> (�[Toor�s) ❑R�mad�eE O Fre E)mnage RIFCWd tcvfew�petsnits:
<br /> []Rtrrouf,asphalt [_.l Rep�ir L;Sfor:n O�mage I h�nrt�a Creok Wa�rshed D'asU�ict{MC'Wt7}
<br /> 45324 P�finne�nka Blvd
<br /> []Re•roof,crdar ❑Res�csraUon [J�'Vai�r Osmags Micanetonka.MEv a5345
<br /> l l€te�-roof,attoer tapociiyl C�y;ain+� CJ O�her.isv��Yk Rtwne, 952-Q7�-0590
<br /> �� �ax: s�z.-a�i-�z
<br /> L'3��f1dQM�{5} ^— �,�7���..��� vt"re��7.fC�If7nr.�hif4".34iEFt_+kettt?
<br /> _ ..... . ....._...... _....._.._ .—�_.__._._._.__—__.___""__.__ ... _._ ..____.
<br /> Estimated Consuuctian Yaluat6on of Rroject(oxd�rding iand) � -_ .. .. .—�-.------._... _ .__ _
<br /> APP'[,ICANT ACKNUYVLEQG�MENT:
<br /> _ -__—.... _ .__ .--._ . _.... ,---. _....._._ __._._ _ ._..._. ____..
<br /> _....._ .......... .
<br /> . ... .
<br /> ; � Agrees da Prouide�p inPorma9ior+raqwired ar�quGsletJ by thc E+cFildir�y E}�zP�rtm�cne;
<br /> . Gertlfees thed Etx>irrforsnatltxk SuppGed!s true�+nd oorre�t t4 tise lreSY o4�isM�er knowl�dgo. Tlxt�p91p�1i r�grpzi!!s thl3t th6y�ro
<br /> soiety respor�sibte fior subrrhiiting a com�pl8te appticaf9an treing aiware�at u�an#�ur�t�do so,tiee staff nas no altgmatnre out to
<br /> rejoct it urti�it is cornplet�;
<br /> • Sortee or aIE of the ir�prma0ian l�i�t+y�au ara asknct tt►pnpvide�rt 1h�,�pp5�ion is c�assifr�d tsy State Oaw sas c�ther pe�vehe or
<br /> corabd�r�{i31. 9rivate d3t8 is infvrm�tian whiuit generally ranrsc0.be gi,ren�ttvP�iic but r,�n be giuen to the subject vf Ctvt!�a�a.
<br /> canfi�hentia!rl�s��;nfarr�ak�ort vrn�r3+�ratry cant3ot�e�+�n��i�er 1na punlic a�a'tro�su61�t af tl�ci�ta, c�a,r yurpas�snd
<br /> in9�nom�f,�e cf th's inlorma�ian is to anrn,aqy updato our rreccords aaid rocortls rst atl�er gwremnreritak agar�r�qui�ed by law. Pt
<br /> youu retus�e 6a_sp�plytt►e u�tormationzt�ue�Gan.ntay,nart�_�ssuect,
<br /> __ _.. . ,....
<br /> App�ca�'sSir�nature_ r �=" [}ate:�� � —m-.�.�..�..,...m„_.
<br /> Ch+mer's 5igrw�h�re_ _ _._...-- Date_ _...
<br /> t85i i�l3tbd:J rr'�dry'20T6
<br />
|