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07lOgl2016 10:03 �A}�} R.002l002 <br /> ' '�` C I t� of �ra tl o <br /> �ullding Permit Application for Maintenance / Replacement/ Remodel -- Residentlal ONLY <br /> (i.e.windows, daors, siding, re�roof, etc.— NO STRUCTURAL EXPANSIdN) <br /> �Q� Ma!ling Addreas: parmit number: aC7 1 (�- !TD 7 `-� <br /> PQ Bax 66 /�, <br /> � Crystal Bay,MN fi5323-ODBB Date��ceived: 7 -/�-� 7� <br /> Street Address: Recelved by: <br /> �� G��.` 2750 Keiley Parkway plan reyiew 4ee: <br /> t,qk�s�o��, arono,MN 55356 <br /> To�, Faa: �� ��.3 <br /> Main: 952-249-4800 Fax: 952-248�818 n .mn.us <br /> This applicatian form must be completed In full and all required infarmation must be submltted. <br /> [ncomplete appllcatlons wlll be returned. (Please prinf) <br /> GENERAL lN�QRMATI4N: <br /> Job Site Addres�: �GjS � y} ��'� „ � <br /> Wfll th[s be a Parade of Homes, Remodelers Showcase Home or other(�Isplay Home? Yes o <br /> lf yes,a specfe!event permlt fs rrequlrod wlth Pol1ce Repartment and CIty CouncJl spproval 80 days prfor to lhe event. 5huttle bus service will be <br /> requlrad unless appllcant demonstretes sufflclent vn-aka paNcl»g!8 dVAIlabl9. Non-permltted evenfs wH1 not ba eNowed. <br /> CONTRACTOR/APpI.IGA T INFORMATIQN: <br /> Name: �Q� <br /> State �icense# L� Expiration Date: <br /> Lead Certiflcatfon Number: - Explration Date: <br /> (for work on homes that were construc ed prlor to 1978 �� <br /> Phone: (ceil) (office) <br /> Mailing Address: City: ZIP: <br /> CQntact P�rson� Applicant is: Contractor / Womeowner �cir�io one� <br /> Emall and/ar Fax: �� , � - � <br /> PROPERTY�WN�R INFORMATION: <br /> Name: r Q,� <br /> Phpne(day): - �Q . <br /> Address: � �j ��rn�,�(S�, �� CEty: �Y QY1 O z1P= ��J�t..P <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall ro'ect descrl tlon: �' S� <br /> Type of Project: Any earth movemettt mey Iso equlre <br /> ❑Door(s) ❑Remodel �Fire Damage MCWD review 8 permits: <br /> ❑Re-roo[, esphelt ❑Repelr ❑ Storm Damage Nfinnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> Q Re-rooF,ceder ❑ Restoration ❑Water Damsge Mlnnetonka,MfV 55345 <br /> ❑ Re-roof,other(speclty) ❑Siding �Other:(speclfy) Phone: 852�71-0590 <br /> FBX: $52-471-0882 <br /> Window(s) www.minnehahacre�k.ors� <br /> Estimated Construct[on Valuatlon of ProJect(excluding land) $ DU <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees Eo provide all lnforrnatlan requlred or requeeted by the Building Department; <br /> • Certifles that the informatlon eupplfed Is Uus and correct to the besf of hia/her knowledge. The eppllaant rewgnizes that th9y�re <br /> solely responslble for submit4Eng�cpmpl�te appllcatlon being aware that upon fallure to dd so, the ataff hes no aftemetive but to <br /> reject It until ft is complete; � <br /> • Some or all of the information that you are asked to provlde an thls epplication is classified by State law as elther prlvete or <br /> confldentlal. Private defe is informetion which gen�rally cannot be gfven to tha publlc but can be giyon to the subject of th�data. <br /> ' Confldentlel data Is Information which generally cannot be given to efther the public or the subJect of the data. Our purpose and <br /> fntended use of thia lnformatian is to ennually update our records and reC4Cds of other governmenEal agencies requirad by law. If <br /> ou refuse to su I th informatlan the a HCatlon ma not be issued. <br /> Applicant's Signature: � Date: ! V <br /> Owner's Signature: __ Date: <br /> Last Updeted:January 20�6 <br />