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.„. <br /> � <br /> � (�1�/ O� �f�110 <br /> Buiiding PeR-mit Applica�ion #or Maintenance / Renovatian <br /> (windows, doors, sidmg, re�raof, etc. <br /> Mailing Addrese: Perm{t number- ��/�� l 5� <br /> �` p0�Qx 66 <br /> �'a`v Cryst�l gay.MN�i3s3-0066 Date received. , 7 � � . . <br /> � � �{�by:� <br /> � � Streat Add►ess: <br /> 2750 Kelley Parkway Plan•rev9ew iee� � <br /> $,a OronO,MN 55356 <br /> TptBi Fee-' . <br /> /1�, 3 �. . <br /> iu��,,: es2-aa�eoo �� asz-2�s-ae�s . � o .us <br /> This�ppEicatiton#orm must be comple�ted in'fuli erx�all required ir�formaiidt'�must be submitt,ed. <br /> lncnmplete appllcatians v�iN be retumed. (Please print) <br /> GENERAL kN�ORMATION: ,��d � �d <br /> Job Site Address: a�C] <br /> No <br /> Wiil this be a Parade of Harnes, Remodelers Show se Home ar other Dlsplay.Home? Y� <br /> lPy�,a spec%I event permTt!s►e4uired with Police�epsrbrient and GllY C�n�����fJony��d e�vente wi!!n�be alla►�ed. �wiN be <br /> reqUired unless applfcant demonstrat9s su�P+cle�►f on�Ite PaM�i�9 <br /> CONTRACTOR/APPL{CANT tNFORMATION: <br /> Name: l� � '0.r���se�N <br /> State License# G1�a0�3 3 6cpiration Date: �l 3 <br /> L,ead Certificatlon Number. � —�� a��83 �' �xpiration Date: y <br /> {f�r wark on homes thaE wrr+e cor+sVtrcted prfor to 79r� toffice) (cell) <br /> Phone: Ze5�� o� ^�Q�" C• �lP: 5S 3 <br /> Maifing Address� 19 C. . � "C" wes+ �Y� v.11� <br /> ���i PersoR: Applicant is: ontra r /. Homeowner �ci«�e oro�) <br /> Emai!and/or Fax' <br /> PROPERTY OWNER 1N�ORMA710�JN'.���t 'v <br /> Name: T <br /> Phone{day): • �"'��� ZIP: <br /> Address: City: <br /> Emaii and/ar Fax <br /> PR�JECT INFORMATlON: ������,y�qui� <br /> Typs of I'ro}ect: AACWD review&permlbs: <br /> �p��s� ❑Rensodei Q Fre Damage Minnehaha Creek Watershed DistrfcE(MCWD? <br /> 18202 Minnetonka Bivd <br /> Q Re-raof,asphalt Q Repeir Q Storm Dameg� Deephaven.MIV 55391 . <br /> ❑Re-raof,�edar ❑Restoration ❑Water�ama9e Phorte: 952-471-0590 <br /> ���.�sp��� FaX: 852-471-0682 <br /> �]R�roof,other(spec►f�►? Cl Siding ❑ ,nnnruv,m'nneh ha .or <br /> �1Nindow(s) - <br /> Qverai! ProjeCt D�scription: � <br /> :�► �� ' a . <br /> �stlmated Construct�on Valuatlan of Project excluding land) S (p 990. d <br /> APPLiCANT ACKN4WLEpGEMENT: <br /> . p�c}nees to provide etl infio►mstion tequired or requested by the BuElding Departmer►t; <br /> Certlfles that the information supplied is irve and correct�the best qf his/her Imowledge- The appitcant reoagn�ss that they <br /> • ere gple�y responsible for submi#ing a compiete aPP�ic�lon being aware that uPan fa�ure ta do so,the smtf has na alte�native <br /> but to reject it un�tl 1t is complete; <br /> . Same or all of the infortn�t�n#hat you are ask�d ta pro�[de On th�8ppfic�fion is Class� bY�� �eW� s'�8t��e or <br /> c4tlttdetiGgl. PrnrBte dat$ is infnrmetion r�A'tidt getleraliy canr�ot be given t0 the publiC but C� be 9iv9h tn th8 subjeCt of th� <br /> � <br /> data_ Confidentlal dats fs informa�on which genersfly cannot be gi�en tn either the publlc or the subject of the data. ur <br /> putpc�se and Entended use o�this informat'°n {s to annuaEEq update our records and rer.ords a�f ather govemmenta! a�endes <br /> uired b Isw. If u se fo su I the tnforn�atlor�,the s licsttom m �ot be issued. <br /> AqnficaClt's SiqnatutA: <br /> p�--� Date: o?�Nau 1� <br />