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t <br /> ���'%1" '2014%THU Ol : i'� ��'I FAX No, 952 854 4909 P, 002 <br /> � �- , � <br /> City of (Jrono <br /> BuiMd�ng Permit App[ication fior In#ernal Work <br /> (windows, do�rs, siding, re-roof, etc,) <br /> Mailing Address: _ <br /> .�,0,�. PQ BOX 66 Permif numt�er: _ <br /> O ^ (� CrySial Bay, MN 55323-0086 Date received: <br /> ( '��i'�^;. ., <br /> ,., ''`�'`�-• a, Streat Add�esS: Received by: <br /> :' �;st� <br /> � ��'������] c~ 275o Kau�y Parkway Plan reviewfee: '�'i <br /> �i����Ki'N1' �J <br /> ��g��s�pg„9 Oronp,MN 55356 ! <br /> WM�otal Fee: � �� � <br /> Main: 952-249-4600 Fax: 952-24�-4696 www.Ci.UrUno.mn.us � <br /> This appfication form must be com�leted in full and aEi required information must be suhmitted. <br /> Incomplete applications wlll be returnad_ (Please prini) <br /> CENERAL 1NFORMATIpN�� 5� �U � ` � � � � � � /��1�� <br /> Job Site Address: l� <br /> Will this he a Parade of Nomes, Remadelers Showcase Home or other Display Home? Yes No <br /> !f yes,a specia!event perm/t Is reqcdrsd witn Poi;ce oepartment and Gity Councll approva/BO days prior to the evant. snutt/e 6us se�vlce wll!be <br /> required un/ess app/Icant dBmonstratas sufflcient onsrte perking is available. Non-parmltlAd ev�nts will not be s/!oY✓ed. <br /> CdN7E�ACTOR/APPLICANT WFORMATIQN: qs Q��ys • G u V 7 <br /> Name: <br /> state �icense# �` �__ T�TD At-r�ome Seivice, Inc, �'-q d, <br /> Phone: � 2690 Cumberl�,ncl Pkw�, Ste 300 rn_ ceil) <br /> Mailing Address: _ ,A���ta, CxA 30339-3913 Z�P <br /> Contact Person: Lic#CR268257 Ph. 763/542-8826 �omeowner (Clrcle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INF M'�jT�IQN_ /'� <br /> Name: �� IJ l✓ O n {){J ��. <br /> Phone(day)� ` RS� '7? - ��l M <br /> Address: O � ! � � Q �G Q�, City: / 1 � `�n � ZIP: J�S� 4 y <br /> Email and/or Fax <br /> PROJECT INFORMATiON: " <br /> Type of Project: � Any earth movement may require <br /> j MGWD review&pennits <br /> ❑ Door(s) ❑ Remodel � ❑Water Damage f <br /> ! � Minnehah�Creek Watershed District(MCWD) <br /> ; ❑Window(s) I ❑ Repair ❑Storm Damage 1 s2o2 Minnetonka Blvd <br /> � Deephaven, MN 5539Z <br /> �Siding ! ❑ Restoration i ❑Qther(speClfy) Phone� 952-A�71-0590 <br /> l ' Fax_ 952-471-0682 <br /> ❑ Re-ro0f ❑ Fire Damage wv�nn�. ehahBCfeek.or <br /> Overafl Project Descrlption: � ! �� Q /J') ,P �1 Q p y7 � �� n � <br /> Estimated Construction Valuation of Project(excl diny land) $ � [� � 9 'r ,�, <br /> APPLICANT ACKNOWL�DG�MENT': <br /> • Agrees to provide all inforrnation required or requested by the Buifdiny Dep�rtment; <br /> ; + Certifies that the information supplied is trUe aftd COrrect to the best of his/her knowl�dge. The �pplicant recognizes that they <br /> ale solely responsible for Submitting a Complete application being aware that UpOn failUre to do so, the staff has no alternativA <br /> but to rejeCt it Until It is COrrYpleie; <br /> � Son�e or ali of the information fhat you are asked to p�vvide on thls application is classified by State law as either private or <br /> conffdential. Private data is inforrnatiol� whlch generally c2nnot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which gensrally cannot be given to either the public or the subJec[ o{ the data. (�ur <br /> purpnse and intended use of this information is to �rtnually update our records and records of other c�ovemmental ayencies <br /> re uired b faw_ lf ou refuse to supply the information,the appfication may not be issUed. <br /> Appficant's Signature� ��✓ �► �—�- p�t�; ( l �r ( � y <br /> Last Updated: 05-U4-2o09 <br />