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.. <br /> City �f C�rono <br /> Buiiding P�mtt Applicat�on ior Maint�ance/Re�p[acementl Remodel- Resldential QNL.Y <br /> {i.e. �rindows, clo�rs, siding, re-rac�f, etc. — NO S7RUCTURAL EXPANSION} <br /> A, Maidng Adtlresss <br /> ���YO PO Box 66 Permit number: �/ ..�/ <br /> Crystal B&ry,MN 55323-0068 Dete r�eiYed: — :/7 <br /> Stre�e#Adahess: Rec�red by: � <br /> s�; � 2750 Keiley Parkway p#an review#ee: <br /> �'�E'st�0��`� Ororto,MN 55356 � <br /> Totat Fae: �7- '�/ <br /> M�irt: 352-249-460Q F�: 952 249-4616 :ci. r mR <br /> Thts application form must be completed in fuli and a!i required infarmation must be submitted. <br /> lncomplate�Pltcetlons will b�e r+aturnad. (Please printj <br /> GENERAL IMFt}RMATIQN: <br /> Job�ite Add�s: - t�'�--� .� c� <br /> Wiit thts ba a Per�dc of o�ems,R�amodeler+s Showutse Homa or other Dlsplay Home? Y+ss o <br /> t/Yrs.a spectal event pertttit�ss n.quireti witlir Po�ce D�a�tt»errt and Aty Couna!approva/80 days ptsrx�the everd ShutXe�s�ervk:e wr7!be <br /> requirad�less appHcant demorrsGates st�f�ent on-sfAs park'u►g is available. Norr pem�itted ev�►ts►w�l t�ot be altcxved. <br /> CCINTRACTORlAPRUGANT INFORMATit?N: <br /> Mame: �'y-v�✓'�'+CW ��N+a-+r�r.�f�,� � �dr►s�r+r�.�i�» <br /> State License# ,/p F�rpiration aate: � ��-4f� <br /> Lead Certificabart Nuraber: lY`�y`� I �.C�+�( -� F.�tpir�tlan Date: '�j/�/'�,-J <br /> {fo�w�rk arr homa�#►at w�rns da pr�a°b i97B <br /> Phone: {celi} �`��'�` 7�3I` - .51"/l_ (office) <br /> Malling Address: f c,� L�. ,�,/ Citl+. �,,.� Z1P: 55 3b <br /> Contact Person: M,'k� ���� Applicant is: on c / Homeowner �cira�►o�� <br /> Email andior Fax: W�,"�{'e. ;� t''t'v�'t.r'vr'ttv 1'£n�e��/►' rsti� �+� �G'�� <br /> RRQPERTY OWNER INFQRMAT10Ns <br /> Name: �i�n �f� e f�`t,.,F- <br /> Phone(day): � -. .. <br /> Address: e�' ��Y� f7f'v� ZIP: �.�,�'`�O <br /> Emaii and/or Fax: <br /> PROJEGT INFORMATtQNt Ove�all �r' ct deacri ti�an: <br /> Type ot Praject: Aay eerth Mnoven�t mey s�o reyuir� <br /> ❑Daor(sj ❑Remodel ❑�ire Damage ������`��' <br /> [�Re-�aof,a�phalt ❑Repair ❑Stqrm Damage Minnehaha Gresk WsMcshed Districf(MC1ND) <br /> 15320 Minnatonka Bfvd <br /> ❑Re-roof,ced�r ❑Restorafion ❑Wa#er Damage Minnetartka,MN 55345 <br /> Phone: 952-�t71-0590 <br /> ❑Re-roof,ather(apeclfYl ❑Siding �other:(sp�afY� �,t"++�iG�e Fax: 952-471-0682 <br /> ❑Window(sj �ld��wte.P"",�`�i '� www:minneriahacreek.or9 <br /> �atin�cea coostn,ct�an valuattat ot Pro�ect Eexduatng�ar�j S �.r.��r�.�-�. �► <br /> APPLlCANT ACKNOWLEDGEMENT: <br /> . �4grees to provide all irr�ormation required or roc�tes#et!by ths Suiiding Depertmer� <br /> . Gertfies that the intormatian supplied is true and correct to the best of hislher knovvladgs. The aPpticant recognizes that they�e <br /> solely responsible far subr►�tting a complete appiicati�bsin�aware that upon failure to do sa,the smff ha5 no a3tematiU've but to <br /> reject it until it is complete; <br /> • Some or all of the 'rntarrnetion that you are asked ta provitle on this appNaation is el�fied by Statie taw as either private or <br /> coM'tderttlai. Private data is information which generally cannot be given tc the pubiic but;ca�n be given to the subject af the data. <br /> Confitle�a! data is ir�formation wh�h gen+sralty cannot be given ta either the public or the subject of the data. Our purpose-and <br /> intended uss of this ir�fo�rnation�s to annu�ly update our reccrds and re�rd�of othar govemmenbl agenass�equired by law. If <br /> ou refuse to su I the informatian the a icatiam m �ot be issued. <br /> � � ��-����� <br /> p+PPticant's Si�tature: �'' ��� + • Date: <br /> ,� <br /> Qwner's Signature: [7ate: <br /> Last Updated:.ten�ry 20f B <br />