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. �.��y vi vr v��u Bu� ing Permit Application for Maintenance/ Replacement / Remodel ,.. t_ �, . . . ... , . .. ,. • , . , C �: ._,�._ . . . ; ;. ;�'. .,, _. . ,; . ..�. . ,. ,� �. ,�� I Maiting Address: Permit number. ,5� � a �O,YO` PO Box 66 Crystat Bay, MN 55323-0066 Date received: — � ' � � � � Sireet Address: Received by: : + � 2750 Kelley Parlcway plan review f .l�,��,��'��` Orono, MN 55356 �. � --. __.._ . Total Fee: �3(�� Main: 952-249�600 Fax: 952-249-4616 This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please prinf) GENERAL INFORMATION: / Job Site Address: 7�� , (,0 U N T y �� p. w pt'y Z.�T�'. M N S�J 3� � Will this be a Parade of Homes, Remodelers Sh case Home or other Display Home? Yes No If yes,a special event permit is required with Police Department and City Council approva160 days prior to the event Shuttle bus service wi//be required unless appticant demonslrates su/f'rcient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/AP ICANT INFORM�10 . ' Name: " SC) �C�L 1, State License# �� 'ctl�'p�-- �.y� ✓ � Expiration Date: '�/3� �� Lead Certification Number: _ —�T Expiration Date: Z t7�� (for work on homes that were s ructed rf 8 Phone: (cel� �� Q' �f (office) , (� � �jG Mailing Address: r,.� City: ZIP: Contact Person: x w�� ,�s/S pi,� Applicant is: Co actor Homeowner �c��ie or,e> Email and/or Fax: 1. �;�� .� � PROPERTY OWNER INFORMATION: Name: �!�'N -f- ��g E'CGF� $OLG PF'!Z Phone (day): q 52 � �}7b — Ob7(o Address: p City:w�}y ZIP: S53 Email and/or Fax: VS PROJECT INFORMATION: Overall project description: Type of Project: Any eerth movement may also require ❑ Door(s) ❑ Remodel ❑Fire Damage MCWD review& permits: ❑Re-roof,asphalt �epair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ❑ Re-roof, cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 ❑Re-roof,other(specify) ❑Siding ❑Other. (specify) Phone: 9521}71-0590 Fax 952-471-0682 �Window(s 5� ,�.��r�v��u�� r_ . Estimated Construction Valuation of Project(excluding land) $ APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no aftemative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is info ati hich neratly cannot be given to the public but can be given to the subject of the data. Confidential data is informatio whi ener I cannot be given to either the public or the subject of the data. Our purpose and intended use of this inform n nu pdate our records and records of other govemmental agencies required by law. If ou refuse to su I the � rma � ,the a ication ma not be issued. ApplicanYs Signature: � Date: �� Owner's Signature: � �/ Date: � �• 3 0 • (5