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� � r <br /> � C�ty of Qrono <br /> Building Permit Apptication for Maintenance / Renovation <br /> (windows, doars, siding, re-roof, etc.) <br /> Mailing Aafdress� <br /> O�"��7' PO$ox 66 P��number: �� � <br /> Q Crystal Bay, MN 55323-0086 pate received: 7�2 <br /> .:;ti �, 3`treet Address: Reoefved by: �� <br /> �� �c,~ 2750 Kelley Parkway Plan review fee� <br /> �'s,�so�� �rotro, MN 55356 <br /> �—�--_-_.- <br /> A9ain: 952-249�-0600 Fax: 9 249-461g wvyw.ci.orono mn y�s T��F�� ` � 7,R� <br /> `�2- <br /> This application farm must be completed in Futl and ail required iriformation must be submitted. <br /> lncornplate alppliaations will be retumed. (Plesse print) <br /> GENERAL INFORMATION: ��2 O ' 1 �(` �� <br /> Job Site Address: J ` � ' '�{� �� <br /> �II this be a Parade of Homes, Remodefe�Showcase Home or other Display Home? Yes No <br /> lf yoa,a specJa(ey�ent permit is reqvired w/fh Police Departmer#e,►d Cny,Councrl spproval BO da s <br /> �equlr�c!ur�fess applJcarK demor�strates sul�cient on-site parking Is avai7able. fYon-pe�d eysnts wiN not��d N�w�71 be <br /> CONTRACTOR!AP�ICAIVT INFORMATION: <br /> Name: ,A����� <br /> State Lioense # '�C,1'3pg Expiration Date: <br /> Lead Certification Number: '✓� 131 <br /> N�A'�� a �'�a83 � 1 Expiration Date: Ylls <br /> (for work on homes that we�e conaLructedp►�or to t978 <br /> Phone: (p$�� o'� —t��. ��- (office} <br /> Mailirx�Address: � .. ..; (�I�) <br /> Contact Person: � � �e' C��' � � Z�P= SS '3 <br /> Ernail andlor Fax: APP���nt is: ritra / Homeowner �c��ao„e► <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> _ a1 m `1f1 <br /> Phone(day); _ s _ _ � <br /> Address: <br /> Email and/or Fax C�ty' Z�P� <br /> PROJECT INFORMATION: <br /> Type of Pro�ect: <br /> ❑Door(s) A►nY earth movement may rsqulre <br /> ❑ Remodei ❑Fire Damage MCWD review�permits: <br /> ❑ Re-roof, asphalt Minnehaha Creek Watershed DisMct(MCWD) <br /> ❑Repair ❑StoRn Damage 18202 Minnetonka Btvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven,MN 55391 <br /> ❑Re-roof,other(apewry� ❑Siding Phone: 952-071-0590 <br /> ❑Other: (specifY) Fax: 952-471-0682 <br /> �Window(s) www.minnBhahacreek ora <br /> Overat! Pro ect Descri 'on: � S � <br /> Estlmated Construction Valuation of Project; excluding land) � �� � ' <br /> � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide a!I information required or requested by the 6uilding Department; <br /> • Cerlifres that the information supp�ieci Is Vue and correCt to the �of his/her knowfed�. The applicant recognizes that they <br /> are solely respmnsible for submitting a comp�ete applicatlon being aware that upon faiiure to do so,the staff has no allemative <br /> but to reject it until it is complete; <br /> • Some or all of the information thai you are esked to provide on this application is classified by State law as either <br /> confideniiai. Pnivate data is ir�farmation whit� generafly cannot be given to the public but car► be given to the subjec�t of the <br /> date. Confidential data is infnrrnation whicfi generally cannot be given to either the public or the subjed of the data. Our <br /> purpose and intended use of this informadon is to annuafly update our record, and records of oiher govemmental agencies <br /> re uired b law. If u refuse to su I the in�ormation the a ication ma not be issued. <br /> A�olicanYs Slanature: �`-� �� � �U� � <br /> �'/' l Date: a U � <br /> _, <br /> z 'd 06T9�G9TS9 3�IA213S 1IW213d Q '8 S I� 9Z �ZT EZOZ SZ Z�C <br />