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Dec, 14. 2415 1 :52PM No, 0007 P, 1 �I�/ O� Q 1"O 11 O � Building Permi# Application far Maintenance / Replacer�ent 1 Remodel (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) Q�} MailingAddress: Permitnumber. p�/,s—d�.s,s � {VO PO Box 66 Crystal Bay, MN 55323-0068• � Date received; /Z—�l`�� SireetAddress; �, 11�T�'"��j Received by: s�, L� 2750 Kelley Parkway � N,��j Plan review fee: �'i�esHo�-� Orono, MN 55356 �2 Main: 952-2A�9-a$00 Fax: 952-249-4616 www.ci.o Total Fee; �5/ � This 2pplication form must be completed in full and all required information must be submitted. Incomp{ete appli�ations will be returned. (PJease print) GEN�RA�INFORMATION: 2�� `�„ y(�� 4 Job Site Address: �'Ti �V Will this be a Parade of Nomes, Remodelers Showcase}Iome or other Display Home? Yes No !f yes,a specia!event permit is required with Police Depanment and City Counci!eppiova160 deys prior to the evsnf. ShutHe bus ServiCE will be required un/ess applicanf demonstrdies SuNlGlent on-site parkrng rs evailable. Nan•permitted eveAts wlll rlof be a110Wed. CONTRAGTORIAP�PLICANTINF0�11A TI�� M'��` �'+pL Name: =� ,q�c(,{,� r� • State License# Expiration Date: Lead Certification Number: Expiration Date: (for work on homes that were construci�ed r;ar to f 978 q Phone: (cell) �1� p- �j (office) �'Z• �'7� l � Mailing Address: � �(L� ZIP: � Contact Person: AppliCanf is Gontrac e� / Homeowner �c�rci.o�a� Email and/or Fax: � �,�, - f� r '�-t PROPER7Y OWNER INFORMATION: Name: p� �,��j��l Phone(day)� 2 �4-y!— � �✓ Address; � �yf� - City; �r� ZIP: Email and/or Fax: p PROJECT INFORMATION: Overall ro'ec#descri tion: Type of Projact: Any earth movement may also require ❑Door(s) ❑Remodel ❑Fire Damage MCWD review&permits: ❑Re-rooF,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCW�) 18202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 ❑Re-roof,other(speciiy) �Siding ❑Other:(specify) Phone: 852�71-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.ora Estimated Cons ruc ion ValuatiQ� of P oject(excluding land) ��"�� p$b�' � �r.r,� ��wiw;n�b ,�na �s G� � �r.,c M�L �5�:�4 . APPLICANT ACKNOWLEDGEMENT: � • Agrees to provide all information required or requested by the guilding Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant racognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative buf to reject it until it is complete; . Some or all of the information that you are asked to provide on this application is classlfled by State taw as either private or confldential. Prlvate aata is informatian which generally cannot be given to the pubi;c but can be given to the subject of the data. Confidential data is information which gensrally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annuaily update our records and records of other governmental agencies raquired by law, If ou refuse to su I the informatio h ' tion ma not be issued. ApplicanYs Signature: Date: �� / Owner's Signature: Dafe: Last Updated�Januery 2015