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To: Permits Page 1 of 1 2011-06-30 13:09:41 (GMT) 17632262355 From:Jeff Steiner
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<br /> •. Cityof Q;ron .: _::-
<br /> BuEli ing eermit;Appli+cation for lnte nal,Work
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<br /> Main: 952-249-4800 Fax:•952-249-46/6. www.ci,orArto,mn:us. ,: ;:;`
<br /> :.,, ..,,. :This application form.must be:co.mpleted,in full and`all:recluaired:1.nformation.must;be.:submitted. :`._, : :.::.'•.:.;. .:;;.:::: :::.::`. .:
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<br /> •. -••••.••••••••:", • • • • • _,..P , Rpticatio.rls•vvtii`be returned .(Please prrrrt) .
<br /> ... ,....::. GE.NERAL aN.FOR.MATIION.:, qop 4 . .. -
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<br /> ...•..'.:.Will.:this;be:a•Parade'of:Homes,:.Remodellers Showcase..Home.or�.other:Display.Monte?::'.: �..Yes:.`.:::.:.Li.:'Nb:; .............. •:".•,:, ::
<br /> ....'.•••••••-•1,- c a special event.permit is required.tvith:Rolice Cepartment end City Council:approval:60:days poor.to.the•event Sheltie,bus'seivice.will be..
<br /> . ..... -<.._. ..{equtred unless v:Olicpnt..deroons ratan surfeient.on-site pariun9.is.avertable...N.a+j=Rem?itfad.**0,. nofbg:nlh iyed.......:'_.::' '
<br /> CPNTRAGT,OR.1.APPLIOANT.iNFORMATION: .
<br /> ,.Name;'_
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<br /> ..••State.License.#. -. • •
<br /> Expiration Efate:'•`. ',�
<br /> •'.Lead.Certification..Number- - Ex,iration l.Da.te;
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<br /> f[orwork.cn.hpm®a•that were conStrucYed:Rrlcrto.?97.8-
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<br /> Meiling:Address . ...., t. i i 1• ..LU.-p � •••NCS✓...........- ..Ci •c1 W', rd5..•,.'ZiP:..S :"�,:' •.: ... ••... -::~
<br /> ,,,•, ..:.., ..•Contact'P.ersom •: ,... ., 3-C . '4?"� t S r ( _• _ Applicant is:. .:'•Contractor::. (`...Homeowner tFirde,one
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<br /> :;..,. ... PROPERTY OyvN.ER:INFOR .
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<br /> ::: . : • • PROJECT INF'ORMATI ON:
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<br /> •••:'•.MCWD.:rekiitw$:porrits: .
<br /> :<; [:]..poor(s) .' D Remodel . Q Water Damage. - MinnehahacreeWa•tefiedDtstriot' CVD)' :M
<br /> ,... •• ,QWindow(s) •: - []Repair _ Q:StarmDamage .. . 18202:Minnetooka:Bvd'' ` :.:..:"'
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<br /> . . .. aSiding : , � Q Restoration0 OtherIsPecify) Phone..:-9aA7 0590 •
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<br /> Re-roof. 0 Fire Damage Fax: 85.2.:47.1.0682.,
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<br /> Overall.Project Description: '. •
<br /> Estimated:Construction Valuation•of Project(excluding land) $
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> ' '-•.-- Agrees..to.provide:'a.ft Information.required .or..r uested by the,Buildi De artment,.,.• ,
<br /> :Certifies that the information supplied,is.true.and correct to-the best of hts/her;knowledge,•••Th.e applicant.,re.cognizes.that they.. -.:;':•..::` :;:
<br /> :are solely,.responsible.for submitting'a cornplete;application being_aware:ihat upon•failure::'to.'do:so,:the staff_:has no:alternative.;
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<br /> •`. Some Or all.of the information.that.you.are-asked to provide.on:this:'application:is.classified by'State:law.:as...either.private.:or:: • :
<br /> confidential;: .Private..dela:is..informatiori..which':generally cannot:be:gt�(en::to:the'pu.blic,:brit:can:be,given:to.:,ih@•.subject::of,:thC:.'::•.,:.:::.::':
<br /> ':data.-,Confidential:data-is:information which._generaNy:cannot be•9iven to:either ttle;.pubitc.or.Pe.subject;of.the data :Qur.• .
<br /> • 'purpose.:and intended.use..of•this:information is:to.:annually.update.ot�r_records and-records,of.other.i9.overninental:agencies`-
<br /> r uued b law if ou refuse to su •1 the information the a••lication.mantbe Ins"=d. •• •• ••: •'
<br /> /applicant's Signature_ ` ®► Date. -� Q••—•%1••\•' •.
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<br /> •.Last Updated: O3-01-2011. •. .'~
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