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Fror�andr�8eryt Fax:(888)4455845 To: Fax:.(952j 249-4616 Page 2 of 2 10l10l2017 1:17 PM <br /> i .�I'�: .. _. - <br /> � A� <br /> Git �►f �r�n4 _ <br /> Y <br /> Buildi�g Perrnit Appi�cation far:Mafntenanc�/Re.placem�n#/R�mod�l �3�sideni�al �?�Y. <br /> _ (i:�. wiric9ou�s,aoe�r�,�Q�Ydn�ry r+��rv�aag,et.�.�.Id�?�1`�Uc-Et3RAL �XR�a�+!,qC�l�): <br /> _ <br /> �} MailingAddress ' � <br /> �x V� <br /> Rf�Box:86 �rta�it[ruta�har � .� � � <br /> . 'GegstBF Bay MN 55323-0066. DBk�.t'�o@�+��d ;� ��"" `«- ;� . <br /> Street Ar1a!ress: . �ec�v�d by <br /> y� ; �� '2750 Kelley ParkwaY Rd�ta r'�+nevu#�e ' <br /> , �, Orora.MN.5�3�6 <br /> , <br /> `��$��a� Tat�1�e ��`:�� <br /> , Main: 952-249-4600 Fax: 952-249-4616 www.ci:arono.mn.us <;. .. ; : : <br /> ,.:: _.. , . <br /> ; � ?his aPplication:form must:be completed in ful!and_all r�q.uir�d.inf4[mation i�nust he submitted. <br /> M.c4mal�e applications.will qe returfled (Piea�e print) ' <br /> GENEl3A�L IN�.OFtMAT1..O.N: <br /> �o�s�.e,Aaaress: �&�'s' .5k�cd r�rd ,�'d <br /> wiil thes.be a:P.arada of:F#oime�e;Fiemocle�a `Sh�►case;Hc�n�or oth�'`piaplay Harie2. Yes ... Na � <br /> . <br /> ltYa�e.a apeFia!e�ent pemth te re�uired tv�tl�.HoflCa DaparfineCrf�nd.Cdy:Eoun(,�l approvai 6R ci4Y+�A�r to tho 4r�drtL .Shuf�lo bus S <br /> wllf:ba . .. <br /> , requlced uNess a�plicant derrwnstrai�st(1fJple�on�eite paddn,g is avaitable. hlon-pem+lttecl events wW notbe albwad. , <br /> _ <br /> CONTRACTQR l APPLICANT INFORM41TIOt�F: - <br /> ,,...... ., <br /> � , � � <br /> Name: >. <br /> _ / 3 _ . . Expi[atio.n Uate: . . .�3/ <br /> State License# <br /> Lead Cert�cation�turober: <br /> /�/�T-3/.xfi�i-�?— Fxpir�t�on Date. . <br /> (forwprk o»trom�s thstwena.�ottarfrocGad Rrioc:#o 1978 <br /> PhOnB: (ceN} �(y-Q�'Z- / 2... (OfFtce) <br /> Mailing Address:. _ City: : ZIR:,. . 0.. .: . _.. <br /> _ <br /> Contact P.erson: ��"? _ . APPlu�nt is: : . <br /> rrt. o .! Mameawner . �c�rae o.�s� <br /> Email andlor.Fax:. � Otov /lt.tit . .. °.` . p�6r _,Q <br /> PRflPERI'Y�WNER>INFQF�AAATION: <br /> Name: ��1 �Sfl <br /> Phone(daY)� 2-8'S71 —5a�1 . _. - - <br /> Addcess: `. _. . CitY,�CC.Qa�St'oi"" /l� �IP:,��3 <br /> _.. _. .., .. <br /> _ .. <br /> Ernait andJor Fa�c _ <br /> _ .. . _ <br /> , _ <br /> `��� ,r na / <br /> PRUJECTINFORMAT10A1: Overall ro'ec�desGn tion: , :d[I`�x [!} .�e.t�ddl";�Si�� / <br /> 7'Ype of Proj�ct:. _ . _ , _ . _ . Any:earth'mov�nt may aiso reguirR �,.. <br /> ❑Door(s) �Fxemodel p Fir.e Damage . <br /> � MC1ND rsvteur$�peri»its: <br /> Minnehaha.Greelc:Mlatershed:Disttic�(MGWD) <br /> Q Re-roof,a�aphalt. []Repair . []&torrn Dameg� 15320 Minnatonka;Blvd ..' . <br /> p Re-Foof,'cedar (�Resto[&Uon �]Wster:,Dama� MinnetQnka,'MN 553� : <br /> . _ • Phone: 952-471=059p <br /> �Re-[oof;other.(�Ra�1v) CI Sid'u1g {]Other.�specify} F.aX. �52-471=0682, ' <br /> '._.._.,-._ ��ndow(S) �nnnu:minneh�hacLrsek:org <br /> _ <br /> Estimated,Construc#lon Val.uation ot Project{excluding l�ncp.. : ..S <br /> APPLICANT ACKNOWLEDGEAAENT: <br /> - <br /> • +4qt!�s to pravi�s..al1�nfo►matlati..requlCed.or r.eguested by:th�Budd�g t�epacGmen�. . <br /> • Certifies that the information supplied Is tcus end correct fo the faes#.of hislhe[.knowledc�e. The;aRpbcant r�cognizes khak:thQy:ace <br /> solely respons�le�nr submilting a�mplete�pplicai'ion�k�ing�re that upon.failure to:da so,:the sta..ff has.na aNemative but io <br /> rejec#it until it ig complete; _. ` _ � <br /> • Some or a{taf the informa�an tha#.you are.asked tu provide on thi� �ppaicakicn is.clas��fi�d::by.Staie law:as:Qitlie.r:priv�te ar <br /> , <br /> cDrtfidential. Private deta is'infotrnatian which generslly cannpt be given.to the pubtic but.can be givan to the;s�j.ect.of:the da1a. <br /> Gonfidentia(d.ata is informa�..o.n wtiich.gecrera{ry•cannot be given to�dbecthe.pt�lic.orthe subject.Rf.the:data.,�Dur purposa..and <br /> iritertded use of this.i . rmatiQn.:�s tp annuatly update our►e�cords�d recQrds fl#other:govetnmenxal�gRndes cequlred:by law_ If <br /> Cu ref�to su I in t� a lieafion ma not be issu�. <br /> Applicant's Signa#ut'e' � Date:. I������ <br /> � <br /> owne�'s Signatute; Date: <br /> Last Updated:Janusry 2018 .: _ <br />