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From:Sandra Beryt fax:(888)4455845 To: Fax: (952j 249-4616 Page 2 of 2 09l20I2017 139 PM
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<br /> Ci�y a� �ronQ
<br /> Bui[ding Permit Applt�ation�for 1IAalntenanGe/Replaaement/R�madei ���Cf�r�#�a���tL�
<br /> (i.e.wFndows,doars, �idlr�g,r�-rc�af,etc.-NO STRItCTURAL EXP.Ai�Sldt�)
<br /> Mailirtg Addrs�ss: ����'� �J'' � '�t' 7���r F,��',;,
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<br /> POBox66 {. t �r,r : �
<br /> � Crystai�ay,MN 55323-�. pg� rs � > �
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<br /> i�'� � . � $��I'�4`* �� a T�'{ �
<br /> S#r8et Atldress: ���� , r �r�� ��� „
<br /> � � �r t.h x a��� �.
<br /> ��, ��`` 2750 Keitey PaticwaY Ai��t��t��t >� ��y��' �>
<br /> �C�� �.� ��,G�.. D.t"Of10,�rJJr3cJ.�. '"` `' th x S ai}� T ru.�,G� rr fi7. .
<br /> kb.H� , # r } 4
<br /> Main; 8.52-249-4600 Fe�r 952-249-4616 wwnnr.ci.orono.mn.� ������' � �� ,� ��=5�,�
<br /> : ,,_. ,. ._;,.
<br /> This applic;atiop forrc�must be c;r�mpleted in fuil and all required Informati�must be su.bmitted,.
<br /> 4nssom.pl@te a,ppiications:�+111.be re#tem�d. ;(P/e�se print)
<br /> GENERAL INfOR.MATION; / l,,� � Q��
<br /> Job Site Address: ��P� �r� ��0� /`�
<br /> Wilt thi�t�a Parade of Homes,Remqd�e.. h�wca�Home or other D7�lay Hcune? Y�s �Jo
<br /> N yas,A apecla/event permlt!s required w'dh.Palf�e Department and Qity Counal sppcoval BD.dAys.priRc fo�e evenf.Sht�e br�s.s@..ks wik be .
<br /> requirqd unless applicant demonstrstes su/Ifclar�t on-site paddng is evada6le. Mon-pemtitted eyenfa w�Vi notb�e sUUowed.. .. .
<br /> CONTRACfiOR/APPLIGANT INFURMATION:
<br /> Name: ��It1z. �f US�-
<br /> State License# .�l'IH 72 G� , Expicati�n.Da#e: 3 3i .��
<br /> ,
<br /> Lead Certification Number: /(f�7'-.3/Z.�a —Z- �xpitation Date: �'�r 2a
<br /> (tor wOrk 4n homes fhat waro co,nstructed prior to 0878
<br /> Phone: (cell) �''jpjj--9'�".�^—�j/Y�- (offioe) : .
<br /> Mailing Address.:. �; 5� QC�� Gr� C�Y� �'��t�� ZtP: . -...�33�
<br /> Contact Person: �f �?d � Applic,ant is:; ontracto - 7 Hom�wner �c�rde ono>
<br /> Email and/or Fax: � �i... �nfL� a r ,o '
<br /> PROPERTY OWNER_I�IF,QRMAT#QN:
<br /> Name: �1L�1'I�1 l,�l12
<br /> Rhone(daY)� �o� _ � . :, dd'
<br /> Address: � � .5 G�.,,t.. City: �` x+�r� ZIP. .�3��
<br /> Email and/or Fa�c
<br /> PRQJECT INFORMAT{ONc Overall roject descri tion: 8'7?01�-Qi9o� ; �- C�;.�����' � ��' ��
<br /> d.�'�. ,
<br /> sfr�� �x %
<br /> _ `...Any earth movema�.may alea r�u1re �'
<br /> TYpeof ProJesct: ,
<br /> ❑Door(s) ❑Ramodel ❑Fire Damage MCW�r�►Iew&periRfite:
<br /> ❑Re-raof,�sphalt ❑Repair ❑Storm Damage Minnehaha Creek Wakershed District(MCW.D)
<br /> 95320 Nfinnetonka Blvd
<br /> ❑�?e-roof,cedar �Restorapon ❑Water D�nage MinnetonKa,MN 55346
<br /> ❑Re-roof,ott�er(specity� ❑Siding ❑�ther.(specify) p�fl�Q: 352.471-0590
<br /> F2x: H52-471-0682.
<br /> �Window(s) www.minneha�creek.oro
<br /> Estimated Con�ruction ValuA#ion of Projec#,(�xcluding:tand} $ �-�"'
<br /> APPLICANT ACKNDWI.EDGEMENT:
<br /> . Agrees to provide all InfarmaGon rsquir�or ra��uested by the Bupding Department;
<br /> • Cedifies tha#the information supplied is true.and correct to the best of hislher.knowledge: The applicant re�ogniz�s that they are
<br /> solely respons�{e for s�m.itting a c�mmplete application being awa[e.tha#upQn'fiaiiu[e to.�o so,#h�.staff.:has nn allemative .put to
<br /> reJect it urrtil it��mplete. _
<br /> • Some or all of the infortnation#hat you sre askad to pcovide an tNis appl�ation is c�assified by Stabe�law as either private.ar
<br /> c�r�fidentiai. Private data is,information wliich generally cannot be gi�en to the public twt can be given to the.subject of the data.
<br /> Con6dentia!data is infvr aUon which gererally rannot be given to either:#he;pud�llc or the.subJect ot th�data-. Our purpose and
<br /> intended use of this in ation is ta annually update o.urrecords•and records'pfotl�er�ovemmental agencies required by law. If
<br /> ou refuse to su I lnto n a IicaUon ma not be issued.
<br /> Applicant's Signature: � Date: � "'���j�
<br /> Owner's Signature: ` Dats9: '
<br /> Last Updat�J:Januery 2616
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