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Page: 7. of 2 11/10/2014 08 : 04 AM T0: 19522494616 FROM: Amy GruSsing PHO
<br /> NE #01281�0743
<br /> City t�f �3r�n+�►
<br /> Builtiin� Permit Application for Maintena�ce � Replacement l Renovation
<br /> (No structura! expansi�n. Only winci�iws, dt�ors, siding, re-raof, etc.}
<br /> r l,�ailir)y Ad:I�eSS- � p@Crt§Bt nUtribeC l �'d �
<br /> f� � ���% � POCiox6F i
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<br /> Crystai Bay, P,��!55323•��6 Date rece�ved ���-��—
<br /> �'' Sire�t:�dtieess I �eGBiv2d by
<br /> �� ' �� 275C1 Kelle par�cva --..__
<br /> � -��� Y- Y � Ptan review iee_ __j����
<br /> � Jrona MN 55355
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<br /> `��=-�'� � TataE Fee.
<br /> ��18in 952-249-460fi F�x 552-2��-4616 i
<br /> ___-----.__.._.._... �...._.�_._. _____ _—._—W._ _
<br /> _.,
<br /> This applicaiian farm must be completed in full and aEl requir�d information m�:st be submitted
<br /> Incompiete applications will be returned. (Ple�.ase prnP!
<br /> GENERAL INF�RMATION: � ,.-- � J/
<br /> Job Site Address: C� � �'�'''"��� � ��__���.�`�..U�...__ _..__._
<br /> Wiii this b�a F'arade of�iomes,Remodeler`�Showc Home or oth�r lJisplay Home��Yes j���y.,
<br /> If yes-<i s�ec�ai e�re.y�.�er,mrt�s req:rireci vti-��f,�obce��/3��trnen9 and wrfy�nunl,�i approva!E�d&ys�no,�to the event. Shuitt2 nus sen�'�"vYil�fae
<br /> ,e��;irr�ct unress����:rc�nd�tfen�or+st��Y�s su'+�;en;c�n-s�te Nert;rrg�s avalla67e �'don-�ermitted er�trts wit!nof be�/lowed.
<br /> CC�h1TRltC70�2 I Al�PI ANT INF(7RMATIUN: r-� �^
<br /> Name _����i�(L✓tGj �L����./._�. ��L. •�- --_ ___
<br /> --�-
<br /> ___�_
<br /> State Lic.�nse# � ,� Expir�tion f�ate: � 2 / '"'"�
<br /> ��.__..�T_��A`�t�—.-� .. _..__�.�. - -
<br /> Lead Certi'icaUan Number VL�'.��_.-���`��__.._.__ -- Expiration Date ��� S� 1 �
<br /> (for work on honres tt�at were cansdrucied�Srior to 7578 .�j p s� � --
<br /> ��'14l1�' r t�j'r.i �✓•- � vL' ( (O�dC2$ i� G�`' �
<br /> W_1�'1��_�.��_`��_.____��_ _. __._._ ?..�.�--' U _.S�
<br /> Mailing Ad�irPss� �Ety � ,�,Z1P ��
<br /> _�..�__���_ .��_._.�'�.../'�-u�__--___..�...._�?'�..�_`-���
<br /> Cor�tact Perso��: , Applic.ant is Con4r�ctor ,' Horneowner (Circla bna)
<br /> - _._ _
<br /> _..
<br /> Ernaii endlor Fax 'L�'� �j�1+'`t',�,.-y ` U2} �,._.t���`�'�-�
<br /> _._ �
<br /> PROPERTY{�W�IER IN� RA�lATIC7N: f�
<br /> N�rn� ��n�-'? !'�'��
<br /> _ __.._ __ __�_ _ .w�...�__._�_.__._..___----
<br /> U _______. ���_ ._. ._ -- ---.
<br /> Phcne(�ay) — ��—�yyY' ��,� j'�'�� _____ �,,r�,,�,�i{.�
<br /> �ddre�s: _ �� City: ZiP.
<br /> _....--.... _ .
<br /> _�___
<br /> �._._„ .
<br /> �n�a�l �n�lor Fax�
<br /> __� _�'�-=-�.-�--��--�_��..�--- � �� _LL ..._ ��_� _���r r�s-�--.
<br /> PF2UJE�7 It+1FORMA710N: Overallproject c�escription �-dC-'�' � ^� 1� �. ' V�� - �- �--
<br /> __...__ __,.___ . ,w.�..�,.___.__ .,
<br /> Type ot Project: ' Any earth movement may atso require
<br /> ',�'")c..��;s� i_'Rer��tiel ❑Fire Dar�age ! IN�CWD review&permits: ;
<br /> �Re-rocf as halt �]Re air '� h�Air;nehaha Cr�ek War�rsr;ed C3istrict��ICWU) `
<br /> p � I�Storrr2 nan�aae 182C��MiFinetonka Blvd
<br /> ;-;R�-r��f,cedar �j Resioration r�Wst�r�lamage C�ee�haven, MN 55391 i
<br /> �'i L�Re-rn��` other�spec�tyl !�Sidirtg ?�]Ot�±ac(spec�`y) � Phane� 952-�i71-0530 �
<br /> Fax: 952-47, 06�?2 �
<br /> _ _ ;'l{U,'�jdowis j '
<br /> — _._� _...___ .._,._ �.�__._�.__.__�.__._� ____... _., ��_... � � m.__.____.� _�
<br /> EstimaC�d Construction Valuation of Proj��f(excfuding land) $ ,� '`�J��. � �i
<br /> AF'PLICANT ACKNCZWLEDGEMENT.
<br /> � . ��F��.� ��,:.;4�_�e ai-r�€orrnation recgu�red�r r�yu�s?�ct by th&Euiiai-�� bepart,�:er., ��� � ��� 7
<br /> • Cer�ifi�s tnat the information s�pplied is tru�and co�rec't to the best of hi�i>ze�Kn�wleuge The applieant recogrnzes that they are i
<br /> ' s�ieiy�esponsible�r subm€tting a cornpfete app9ic,ation heinq aw�are tnat upon fai:ure Co do sa, fhe stafl has na alternative but to �
<br /> � ��ject it u��ii Yt is�ompiete:
<br /> �� r Some or a1i of the infarmation that you are ��k�d .o provide an ,his app{ication is classified by Sta#e �aw as �i#ner private or �
<br /> ��ntideniiaL �'rivat�data ;s�nf�rn�atinn which ge»�ra!!y cannot�given to the public bui can be given Eo the subjeef c'the data ;
<br /> (�onfidenUal d�?a is infiormatit�n which generally car.nat be giv�n to eith�r the pub9ic e�r th�sub)ec#of the data Our�urpose and �
<br /> �n±er?d��use of this informaiion is to annually upd�ke our reca��s and records�f other gflvernn7entai agencies required by law ff �
<br /> ! y,>a rei,�se to suppfy the ir�r�nnation, e a i�cation ma nof:�e�ssued - ----------,
<br /> .._..._. .��...,..EE._.,,.�........_._ Y' __ ._ �
<br /> Appiir,anf's Signat��re� � '� C?ate: �_ �� .���
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<br /> Qwner's Siqnature: Date �___._ __ �
<br /> E.�7t t3pd�t�d'G3t0�1�C�13
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