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To: City of Or'or�o r'ac�e 2 of 2 20'13-'1 O-'I O '1 G 'I�J:'I O (GMl) '16�Z3'JSS3'J2 F�om. �:toim C'.roup
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<br /> Burld�tl� perrnit '�+1��/ {a f �t
<br /> � '�ppJicati4� f�r +�nq
<br /> -......,,,,_,�I-_..,Va stru�turai ex ��int�na��,� f �
<br /> --�--.�.�....,..,,_, p�nsion. Dn� ��lacerr��nt,I
<br /> �Q � vwind4�;�
<br /> � , d�ors, si�in Rertovat�t�n
<br /> �i Marrinyaad� Jr re�rQof
<br /> ss: � etc,�
<br /> �'p Box 66
<br /> `�""`.,.-,-�-�
<br /> �rystal Bay,tvlN 553Z3.QOg� Perrnft number. �
<br /> � Qate r
<br /> �' ,� : StreetAddress� eceived.
<br /> e� t
<br /> `���.=;..y G ufoU Kell�*v a���,,,A; Recei�wi h�,.
<br /> �' � �,M�155�� '
<br /> Plan rewiew fee
<br /> Mair�� 952-249-�464� Fax, 952-249-46'� �
<br /> This ap�licatlan form must bt c4rnpleled i�ta�l a d�a\'�r�, u����,� To�a��ee� j�4+�
<br /> t 0 ,
<br /> `� ` `�, ��������D111�`1'���.b��1�`D�11����
<br /> 1�l�CI��ete a �"r '
<br /> GENER�aL 1�1�4RM1ATibN. � � pp �B�IOID�WI�� �e f�'�1lCit�{�. (I�1��SBprira�,}
<br /> Jab Sit�Address: }—11��i�,�� ��-._��`. �
<br /> Wiif thi$be a Parade af FMatm�s,➢�e o �Cers Shawcase Horne or r,tnQr DispPay Home7
<br /> /f}�es,a spe�+a1 eWa+�t perntit rs r$c�uiFed wlfh Polar�Dspertmerrt��td�y�y�aun�crJ appr�,va!BO days prior to the��+en�YGa 4us serviee�wp pe
<br /> requiced unless appJicant demonstrates srr/flcier7l qn-srte parking rs ava�lable: No�permrited evenls witt nof be a/lowed.
<br /> CQIUTRACTOR!AF�PLPCAN7"tNFC}RMA1"IK)N;
<br /> �lame ,, � �1* �`�d""�.. �''��` �„�',,::�.
<br /> State License# Expiratican D�t�:
<br /> --�
<br /> Lea��e�tif�eatian N�tm er; ' � I �CJ�,�'
<br /> (for work on hor►aes fhat were canstrutte�f prit�r to 19 8 EXP����CiOn Date �
<br /> Phane. (�ell) �.0( r� � � (atfic2) �1�yr� �
<br /> Mailmg P,ddress` �����___, �
<br /> � . C�fy: ' - �� ZIP. �"��"�2
<br /> Conta�t�erso�: ,�� ApPla�an#is: orrtractar / Homeowner
<br /> Email and/or Fax. r� � rc,rcie anea
<br /> t�-v�` -•---�-�'�-�� {. .� '
<br /> PROPEf2TY�iM1�JER rNFQE?MATtflN; ' �
<br /> N�rne. �
<br /> Phone(tlay): �, �
<br /> Address: • ' —
<br /> Giky: ('Z3 ZIP: s�
<br /> Emai►and�r�r Fax: ` ,�; �;, ., ��� : ;
<br /> PRO,�EG�'tNFQRMATI�N: {�veral!pra�ct descri tion: �j ' , � (`
<br /> TYAe of Praject:^ " 1'.'.'.C�"�
<br /> Any earth movement may aisa require
<br /> �Daar(s) ❑RemodeF ❑Fire damage MCWD review&permits: `
<br /> �Re-roof,asphalt Q Repair ❑SCorm Damage ��nnehaha Creek tNafershe�l Disirict(MCVWD} �
<br /> []Re-roof,c�edar 18202 Minnetanka Blvd
<br /> ❑RestoraUon ❑tN�ter Damage
<br /> ❑Re-roof, other fspec� Deephaven,Ml� 55391
<br /> �Y) �]Si�ir�9 �t3ther.(specify) , Phone: gS2-a71-0594
<br /> ❑Window(s} Fax: 952-471-q6$2 1
<br /> www.man raehaha�reek.�rq
<br /> �stitTa�ted Constr�ctioo� V�luation of Project(excluding land� $ �,�;,,�
<br /> 7
<br /> APPLlCANT ACKNQ4ULEDGEA+IENT: T�
<br /> • Agrees to provide all infprmakion requir�ed or requ�sted by the g�ilding Department,
<br /> • Cer�ifies that the infprmation suppGed o�true and correct ta ahe best trf his(her knowledge, The appl�cant recognizes tt�at they are
<br /> salely r�sp4nsibie fpr subm�tting a ccrmpiete applicaUon being aware lhat upon failure to do so,the staff has no alfernative btrd to
<br /> reject it unt;l it is complete
<br /> • Same or ai� of th�e dnfiormacion thaf you are asked to provitle on this application is classified b� 5tate law as either private +pr
<br /> eonfidentiaL Private data is infarmat�on w�tfch generaqy cannqt be given to the p+�bBic but ca�be giuen ta th�subject of the data.
<br /> Ganfidential data is information which generaily cannot be given to'e�ther ihe pu�lic oX ing subject of th�dafa. C3ur purpose and
<br /> intended use of this infarcnatian r�t4 annuaily a�pdate our records and rec�ards of afher�govemment�l agencres�equired by Iew. !f
<br /> ou refuse Co su ! the informatian,the a lication ma not be issuet@.
<br /> �4ppliC�inf°s Signature: p._.- � ��
<br /> Date:
<br /> Qwner's Signafure: Date:
<br /> Last Updatad:(}3Y051202 a
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