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06/24/2014 18:39 9528885554 PAGE 01
<br /> City of �ront�
<br /> �uilding Pe�rmlt ApPl�cat�on for Maintenance f Replacern�nt 1 Rena�ation
<br /> (IVo structural expansion. On�y windows, dor�rs, siding, re-roaf, etc.) .
<br /> ........ .. .. ....:..... . :.....,:;�, .,�:� , ,.. ,;�,
<br /> M�ilingAddress: �.l?�Y.'�il��r�r�i�l�¢�.���,�•. ° � � ' .
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<br /> f1T PO Box66 ,;��s:'�.i; ,,ii �di�i;�•,.. ,.,'� ,;�;+xn,�:.
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<br /> �7 N 55323.oass �:���A;i��;�,�ii���,�,.,,.�� . � ' :� ,:
<br /> �. Crystel BaYr M I I• .. �.��:i1 U1jll;'I•�:�,..,. nh.i�; i' j�qe I,
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<br /> . s�eraddress: ,;,��,,�a� , �,p,�,�:� , .• . ..,��.�;"... ,:;,�:,��,;;,.,
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<br /> 1 2750 KMN 5356 � r,�� .,,���,r�.: •:ii � ,.,; ,,:. ,,; • �,..,...,;,,
<br /> q+' • OTono i�,�'��� :;�lfi� .m,;�I,,r:'!" �n rrr,�y/�y
<br /> 1' ��,4'r Ii`�,�`'�'�.i� .,�,I�pi ,���,}4+�"r:�, I I.';:
<br /> $ � ,i,l.�.il��•�'%��"� ., r��, �.,.,";.�,�,,��
<br /> .c rom m�.0 ��.r. '",'r""'""•":, �•�i:�: :c.
<br /> Main: 952-249-4600
<br /> Fax; 952-Z49-4�616 : ,.��!�I I':�:...,�:ii'��::�:_ ., .,, .
<br /> This applicatlon form must be complsted in full�nd atl required information must be submitted.
<br /> incomplete appllcati+�ns will b�returned. (Plea�se print)
<br /> GENERAL INFORMA71C1N: � �� �'�k,� I �
<br /> Job Site Address: ` Yes NQ
<br /> Wilf this be a Parade of Homes,Remodelers Shawca Home or oth r isplay H �?
<br /> N yes�e SA raqulred unl�appl�lcert�mot►S�r+�s�utf'clenf a»sfta prH�rr9!s ivai�bl�'Nen-permlhod 9vents wl�not ds allowsd ���(�be
<br /> CONTRACTOR l APPLIGAN7 INFORMATION:
<br /> Name: ' �
<br /> State License# � G, 4, �xpiration Date: �-��ry'�]1�,.-
<br /> Lead Certiflaadon Numbe�r'. �"�"' •- .�c��S"Q�-- Expiratian D�'te: (o `�S'-
<br /> (for work on hames�Qhaf wgre constructed pNor Lo 19T8 (office} Q,�� — �S��^��S U
<br /> Phone� t ) 1 . ��,�'; � C��:-� + ZIP:�S-Ya.�,
<br /> Malling Address: ca1 � � pppticant is: on ract ! omeowner �ci►�a a�e�
<br /> Cont�ct Person: �}��������—
<br /> Email andlor Fa�c: ��Qys,,L,���.��
<br /> PROPERTY OWNER INFORMA'TION:
<br /> N2me: ��2. ��`��
<br /> Phone(day): !�_�----��yGt`�'"-� �� _ C;�, ZIP:
<br /> Add�ess:
<br /> Email andlor Fax:
<br /> PROJECT INFORMATI�N: ave�all ro ect descri �ion: p�y earth movement may a{so requlre
<br /> Type of ProJect: MCWD revlaw&permits:
<br /> ❑poor(s) ❑RemodOl ❑Firs bamage ppinnehahs Creek Watershed Dfstric4(MCWD)
<br /> �Re-�oaf,a5phalt �Repa�r [a Storm Damage �g202 Mlnnetonka Blvd
<br /> R�stdratfon ❑Water Damage Deephaven,MN 55391
<br /> �]RB-roof,c�dar ❑ phane: 952-471-0590
<br /> Q Re-roof,other(apec�f5+) ❑Sidin9 0 Other.(spsciiy) FBx: 952-A71�0662
<br /> ^ [�W(ndoW(s) , . �n�eh aCi88 -�
<br /> �'3 '�rf.� t?[�
<br /> �stlm2�ted Construction Yaluation af Pro)ect(excluding land) � - -
<br /> APPUCANT ACKNOWL,EDG�M�NT:
<br /> . Agr�es to provide a11 informa�tion required or requested by the Building�epartment;
<br /> . Certifies that trie lnfarmatian suppliBd is true and correct to the best of nis/her knowledge. The applic�ni�ecognlzes that they are
<br /> �lefy responsible far submitting a complete appllcation being aware that upon failure to do so,the staff has no attemative but to
<br /> rejeCt it until if is Complete;
<br /> � 5ome or all of the inFormation that yau ate asked to provide on this appflcation Is clas5ifled by State law as elther private or
<br /> confidentlal. P►Ivate data is in�ormation whieh generaAy cannot be given to the public but ean be given to the subject af the data.
<br /> Confidendal deta is inform�tion whiCh gene�elly cannot be given to elther qhe public or the subJect oF tha data, Our purpose and
<br /> intend�d use af this ln¢ormation is to annually update our records and recotds of other governmental agencies required by Iaw. If
<br /> ou rafuse to su l the informaHon,the� fic�tion ma not ba issued.
<br /> Applicant's Signature: ��'���-------'- ���� bate= ��
<br /> Owner's Slgnature; Date:
<br /> Laat Updated:03I06/2o13
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