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AP�u' 27—_�010 04 : 12 PM WALKER, ROOFING 6512510916 P. 92 <br /> _ au��u���y �������� r�NN��c����r� ��r inierna� nror'Ic <br /> windows, doors, sldin , re-roof, etc.� <br /> �.0� Me/NnP �6. Pemlltrfumbe,r. O —DO s <br /> � Q Cryetsl Bay, MN 56323-0066 Doba,tecelvsd: /rj <br /> � � SHset Addrsse; ReodMed by: <br /> 275Q i(elley Perkway Plon revloW tse: <br /> � Ororta,MN 63356 <br /> __ To��Fe.� J �`�33 <br /> Maln: �82-249-4600 Fox: 852-249-�816 �pp�y,�l:pr�n�.tnn�a <br /> Thle applloatlon Torm mu�t be ccmpleted In full and all requlred informatlon mu�t be aubmltted. <br /> Incampl�applicatlons wlil be r�turned, (Pleeae print) <br /> OENERAL INFORMATION: �`�� .--�J_ Q�� �/`� <br /> Job 81to Addreas: `� !� /�J'+�.. <br /> WIII this be a P�rede of Hcmes, Remodelers Shcwcase Home or other Dlsplay Home? Yea No <br /> K yss,a apeo/al�vsn�pomik b ipu�hsd wkh PoIIoe D�rbnsr�t�nd CHy CouncN ippro wl e0 d�ya p�or(o Eh��wnt Shukle b�s sewlo� IN <br /> �Wbsd(a�hs��ppNornt dsmonahai�s�ull'!elant orr�IN�M►kM0 4 a►�NabN. Non-pumAY�rd�wnb woUl nof be eMoand. <br /> CONTRACTOR/ApPLICANT INFORMAT N: <br /> Neme: Q� �� � <br /> St�ta Ucense�M .�-y Expiratlon Date; - - /� <br /> F'hone: /- �v �o office cell <br /> M�ill►�Address: Ci • ZIP: � , <br /> Contact Per�cn: • Applicant ie� ontrector Homeowner �oi� ona� <br /> Emell and/or Fax: � �, �-a i <br /> PROPERTY OWNER INFORMATION: / <br /> Nama, o �a"� <br /> Phone(day); z- — D <br /> Addre�m, r Cit : ��h� 21P: <br /> �mall and/or Fax ' <br /> PROJECT INFORMATION; <br /> Typ�o�t ProJect: Any aarth movement may roquln <br /> MCWD rovl�u►�p�nnits <br /> ❑f?oor(e) [J Remodel ❑Websr par»aeo <br /> Minnohqha CrookVl�torghed Oistrict(MCWpj � <br /> ❑V1Andow(s) ❑Repalr ❑Storm Damepe 182�Mlnnetonka Blvd <br /> Deephavon, MN �8361 <br /> ❑Sldlny ❑Ra�rotlon ❑Ofher:(op•cify) Phone: 852-d71-0690 <br /> o-roof ❑Flro Damape �ox: oa2-471-0882 <br /> �minnehehacreek o� <br /> Ovorall Pro ect Doecrl llort. p- � <br /> Estlmet�d Conehuctlon Volu�tton o1 Pro�ct cludln land 5 <br /> APPLICANT ACKNOWLEDOEM�NT: <br /> • Apn�o m prvvldo all Irdormotlon requlred or roqusstPd by the Bulldlnp Deparonent; <br /> • Ce�ilNeo that ths iMbrmetion oupplled la bve ond oomect to tt�e bo.t of him/her knowlod�, The appllo.�rt r000pnlzea thst they <br /> �re eolely rospon�ble Tor submltUny a oomplsoo sppllcaUon belna avv�n that upon failuro�o do ao,th�s�ff ham no al�.mative <br /> but to roJ�ot It until R lo complete; <br /> • Some or ql)of the Irtfarmation tlwt you aro aolord b provldo on this eppllcatlon la olasslfled by 6tete law as�Itlwr privat� or <br /> confld�ntiel, Pr1vo� dom fo Informa�on whloh p�norally o�nnot be Alvrn Oo }he publlc but oen be �Ivan b ths subJect of the <br /> data, Ccrttidentl�l d�� Is Iniomt�tlon wh�h Sener�lly cqnnot be piven to olthor ths publlc or ths subJmct ot tho da14. Our <br /> purpoae and IMrnd�d us� of thlo IMorm�tion lo to ennually upda6o our r�oords ond r000rdm of othor govemmer�l anenoles <br /> ro uired b law. If u r•fuao 00 ou I th•Irtformation the a Ilcadon ma not be Issued. <br /> Appllcant'8 8lgnature; Date: ��7 ��(� <br /> L�at UpdeDed; 0�04-Z006 <br />