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To: Permit Desk Page 2 of 14 2016-04-21 19:14:37(GMT) 15072999410 �KRISTIN LO FLER
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<br /> Buifding Permit Applicatio aintenance! Replace / Remodel W Residential ONLY
<br /> (i.e. window urs, sicfing, r�-roof, etc. -� �! RUCTt�RAI. EX�ANSI�N)
<br /> ��A'%� rvtailiPO Bo r66 Permit numbor: 2 - � �
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<br /> / � ``, Crystal Bay, h9N 55323-0066 Date received� ��.ZI � I
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<br /> �; � , h I StreefAddress: ` Received by_ I�►-'"
<br /> --__ ___.__._...
<br /> �,-S� �;` 2�50 KeNey Parkway Plan ro�licw fee: � _
<br /> \ � tiL% C7rono, Mhl 553��
<br /> � '�xes����-/ �rL�
<br /> �___._� Total Fee;
<br /> Main: 952-249�600 Fax: 982-249-4616 �.vw�.^;.ci.oror,o.mi�.us - ��
<br /> This application form must be campleted in full and all required information must be s�abmitte
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<br /> Incompiete applications will be returned. {�'Jsase prirrt�
<br /> GENERAL 1NF'ORMATION:
<br /> Job Site Address: Z��3 S,�.a��,�,�,� t�;_��_ .Ck�,�� t-tN SS��'�
<br /> _ ,_.__ __T
<br /> Will this be a Parade af Hcrrnes, Rema+delers Showcase Horne or othe�0isplay Home7 ❑Yes�No
<br /> !f yes,a speGial evb�i p�rmit�s required vvltJt Po�'1Ce OCpt?rtmont�nd Crty Courcit approva�50 4yays,�rior to the evenL S'rrc�Yt�c bus service wil!he
<br /> raquir�d unless appf.�cant dernonstratss sufficisnt on-siie p�rk;ny rs available, �Vv!�-permitteo evenfs wrrl nvt i�e allowed.
<br /> CONTFL4CTOR I AFPUCANT INFORMATION:
<br /> h�fame: G-��-,ot_�-� �1���h-..��.�- �-�4.-�r,,�,
<br /> State License# �s ti�-�3 �� _ Expiration Date: �; , •
<br /> - - _ ,
<br /> Le�d�ertification Number; �,�;�-- G���,�`I -7 Expiration pate_ -3 �� ��
<br /> _ . ._ .�
<br /> (iar work on homes th8t were canstructed prior to 1978
<br /> PhOne: {Cell} Sc;`� -"3`�Z- �ct"�1 (offiCej �"��z - 3�;"7^ tUsa1
<br /> . —_... _ . .
<br /> Maiiing Address: ���_�c;o�y ��� tyz.. ___, . .__ CitY_ M.a�ti�-�. ._ _ ZIP: S�,cr, 1.. __
<br /> � _..,
<br /> Cantact f'srsan: �-,����_,� ���,t, _ � Applicant is: Contr�ctcir� J Homeowner {Circle One)
<br /> Email andlor�ax: n,,;���.�<<�. _
<br /> � �. �'h`-r�{%i�L_�'z��.r-�cr,-4. L.c�w-�
<br /> PROPERTY QWlVER INFORMATIOfV:
<br /> Nr']Rl@: �"�-� ._��r=1�2._`+,i.K.f2.
<br /> ---_ _ __
<br /> Phone(day): �;^Z��:' ���c�
<br /> Addre$s: ZL-c�3 �:�n�t�...xLc� �o City:....�}rt�,...,� ZIP: 55�3.�
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<br /> Email andlor Fax: ���,,,�,-��t�;;�,.,,��,�,��,,,,,.,
<br /> . .-- ___ . . _.. _
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<br /> PROJECT INFORMATION: Overall project descri�tic�n: `(1����/i�? " 6G'I % / G
<br /> ---- -- .a _. _
<br /> 7ype of Project: ' earth movement may also require
<br /> ` ❑ Door{s} � MCWd review 8 permits:
<br /> ❑ Rerr�r�del _, Fire Darnac�e
<br /> ❑ Re-roof; asphalt ❑Repair �Storni Damage Minnehaha C�eekUVa:ershed disirict((viCWDj i
<br /> 15320 h�linnetonka 81vd
<br /> ❑ Re-roof,cedar �Restc�ration [1 UVater Damaqe Minn�tonka. tv1N 553d5
<br /> ❑ Re-roof, ather ispecifyy ❑ Siding QrOther: (specify� Phone: 952-471-Q590
<br /> t����r� -r.z�� 4 S+�:w��? Fax: y52-471-{lua2
<br /> ❑Window;s) -,�`�.�? _��,As�+-+���-+r �,vw�.v.minnchatracreek.orc�
<br /> ._.. - --._ .. ___.. _..... .. _......... _ __
<br /> Estimated Construction Valuation of Pro�ect�Qxcluding land} $ �ioG'7.��
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> .
<br /> • rlgrees to pr�vide a11 information required or requosted by the Building Dapartment.
<br /> • Certifies ihat th�in�rrnation suQplied is true and cnrract to the best of his;her knawledge. The applicant reca�niz�s tl,at they ar�
<br /> soleiy responsible (or submitting a complete application being aware that upan iailure to do so,the staff h�s no altemativo but to
<br /> reject lt until it is compleEe;
<br /> • Sorne ar all of the infarmatian that you are asked to provide on this appi+cation is classified by State law as either private or
<br /> confidential. Private data is in(armation which generatly�anr�ot be yiven to the public krut can be give� t�the subject of the d�t�.
<br /> Confidential data is information w}iich generally r,annot bc given ta either the public or the subiect of the data, Our purpase and
<br /> inter�dad use of this infarmation�s to annually update nur recores and records of other governmenta!ayer.cies required by law. If
<br /> you refuse#o supply the information, the 2pplicatian ma�not be issued.
<br /> Applicant's Signature: � C'`� �`-�"'�' Date: �{�2[ - S�
<br /> awner's Signatuec: Dat�: __.
<br /> Last Updated:January 2015 � /,
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