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LAKE SHORELINE STABALIZATION <br /> PERMIT APPLICATION FORM <br /> MINNEHAHA CREEK WATERSHED DISTRICT (MCWD) <br /> 15320 MINNETONKA BLVD. Ph: 952-471-0590 <br /> MINNETONKA, MN 55345 Fax: 952-471-0682 <br /> 1. Property owner information: <br /> Name of each property owner: I K-4-AN -i` -\6O� <br /> Mailing Address: 11210IA-- ;t(kV-Ji I17,`�City: ` ��� State: �it\( zip: 35) <br /> Email Address0,-\f 1` — �cs �g�l�c3t �� ,1�,COI-TN Phone: tV)21.F-500,_46 <br /> 2. Contracting company information: <br /> Business Name 4 L{E PC- Representative Name M LA'-" TE120 <br /> Business Address:4`.5a) ,f j We- Citynn-I k lL. State: 1' Zip5510 <br /> Email Address: I 60(-1:-.0.116 Vt4,C nrcTh Phone: .mac I1n - 6 <br /> Ongoing performance bond with MCWD: [Pres ❑ No Bond Number: Lel ? X 1 15 <br /> 3. Project Details: <br /> Project address:\ 1Q �vlL,DE} '( �1(_ City: a QQk.O State: HKI Zip: 5' ) <br /> County: kkEk(N(eF(N Property ID number (PID): O1 t \1a 3\0015 <br /> Type of Project: ❑Vegetative restoration ❑ Bioengineering (Wprap ❑Retaining wall <br /> In-kind replacement: Kc <br /> Yes ❑ No Erosion intensity score (if not in-kind replacement): <br /> Located on lake: 1'1 I O t\-W- } Length of shoreline affected: I t 6 (lineal feet) <br /> Describe any existing structure along shoreline: SC_,O,ti- .t �.OGK. �'�V13 j int() L_cct e <br /> Access to project site by: ❑Ice tlarge El Upland corridor <br /> Financial assurance bond acquired: ❑Yes ❑No (If not an ongoing performance bond please fill out next page) <br /> By signing below, I hereby request a permit to authorize the activities described herein. I certify that I am familiar with MCWD Rules and that <br /> the proposed activity will be conducted in compliance with these Rules. I am familiar with the information contained in the application and,to <br /> the best of my knowledge and belief, all information is true,complete and accurate. I understand that proceeding with work before all required <br /> authorizations are obtained may be subject to federal,state and/or local administrative,civil and/or criminal penalties, <br /> _ -- '7/9/ <br /> Signat g t e of property owner or contracting representative Date <br /> Page 1 of 2 <br />