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11/ �,015 08 : 21 T0: 19522494616 FROM:6123544154 Page ; 2 <br /> ���'� �� ����o <br /> �UILC31Nt� P'EhMlI�' ,��F�L1�AT10�1 <br /> Ft�Ft �EIIV �TRUCTIJRE� C3R �1DDITIt�NS <br /> �,r-� ;~ Mailing Flddr�ss: ��l S (� / � � <br /> / �1��� pQ go��� Permit number: <br /> �� � Crystal Bay, MN 55323-0066 Date received: ���� <br /> ' Street Address:' heceived by: <br /> \� ' � 275U Kelley Parkway Pian review fee: /' 3 <br /> '``� � " Orono,MN 55356 �� <br /> ���est�a �` ToEal F��: � <br /> �1 <br /> Main: 952-249-4600 Fax: 962-245-4616 vv4vwr.ci aronc r�n�us � <br /> �� This application fiorm must b�con�rpiet4d in fuli and a(I re�uired informafio«�must be mitted. �� <br /> lncomplete applicatiaits wilE be returneci. (Please prrnt} ������ <br /> GENERAL lNF�RMATIiJN. X <br /> �� ��b Sit�Address� �,-��'�_��- ����-� .` �' - C�. <br /> Vtfill rf�is be a Parade of Homes, Remo elers Sh�icase Home or other Display Nome? ❑ Ye� ��❑ Nc <br /> if yes,a specia/event permit is��ryuired with Police Department and City Counci!apprcval 60 days prior to ihe everf. Shutfte bus service�ritt n� <br /> required unless applicanf demonstrates suflicient on-site parkirr�is available. Non-Germitted evenfs wrfl aot be aAovied. <br /> CCJNTRACI"OR 1 AP tC �1T INF , M�7It�N: <br /> Name: _ �t�- ���1.__....�L�,.C...�-1 ___.. - -- <br /> State I�icense# Expiration Date: <br /> -- — --- <br /> Phane: _�c II � "���_ _� , office) �j� . (��--�-�.,�__.__ <br /> � Mailing Address: ` (�,� Cit . r' ZlP: <br /> -- � �t�--- ��-��� - �__�._.._�a�..a}�_�. <br /> Ccntact Person; _ ___�'���.�x, Applicant is: ra� / Homeowner {c�.���one2 <br /> Email andlor�ax: �(�,' �, _� ' � . ��1�f�:�1�'"►�Y�-_�C <br /> . _C3.�---___, _�_ �____._ <br /> PRC}P�RTY OWNE INFORMAT ON: , <br /> Name: � � '(�G <br /> � - �`�� ..��--- _ __--- __�___. -- <br /> __ — -- --- ...__._. <br /> {'hone(day): _ �}�� _� � _ <br /> - -_� � ��_� <br /> A�dress: _ .� --- '� - �=ir_'���C:i�'--=�`r„�.,e� ____ Crty�Ct�'j��---ZIP'���_�__ <br /> Email and/or Fax _����,_. irt����,�1�_La.l_4-�. <br /> �aR�HITECT t ENGINEER INFORMATf�N: <br /> N a n1e: <br /> Phon�(day): _—. - ---.. — <br /> �ctdr�ss: ------ --- ____ __ ___._. City: ZIP: <br /> En�ail andlor Fax� � <br /> ! � � �, �� ` ` t�- d1�- �i <br /> 1�F�bJEC�' INFb AT 0���D ri Cion_oY"�ct�� .��'C�'� � . �', � G' IiL1 ' i'��� <br /> ' 1.7ype of F'roject 2. P posed Use ', 3. Str ure Type i 4. wage Disposal& � <br /> � ; Water Supply � <br /> ; �.1 New Cnnstruction Sit�gle�an�ily with , Residence i <br /> j ❑Addifiot� atfached garaye I� ❑ Garage l Accessory Bidg, ❑ PubEic 5ewer � <br /> � � ❑Acc ssory Building ❑ Single�amily wilh ; ❑ Deck I <br /> ❑ F2 �cation detached garage ' ❑ Office/Co�7unercial �' � <br /> � ' t17�r: s ecif � ❑ Private��wer 1 <br /> ; ( P Y) �V�`��� ❑ Multi��le Family(Condo ,' ❑ W�reftause <br /> � ! ❑ Puk�iic ' �, Storage ❑ Pubiic UJafer ' <br /> � °'Any eartfi movement may also r�quire ; ❑Commercial ; ❑ Other(specify) <br /> � i 1U9CWD review&permits. ( ❑ Industrial � ❑ Private Weli �� <br /> �, AAinnehaha Creek�ldaiershed Districl(h1CWD) ❑ Oth�l': (SpeCffy) � ' <br /> ' 18202 h5fnnetcnka Bfvd <br /> � De2piiaven,��N 50391 — � � <br /> i Pht�ne: 952-4?1-�590 <br /> ' www.tg nn2ha O Seek.or; - --.__ . --- __ . __---- ----..__. � -s;�,� __. - _ ; <br /> �. <br /> Estimated Construction Valuatit�n (excl�lding land) � � �`� ��� <br /> __... __--�`-'__ _-----..... <br />