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. �� �a73 - <br /> Buiiding Permit Application fa MainteOnance/ Replacement/ <br /> (No structural expansion.Only windows, doors,siding, re-roof�, etc.vation <br /> �QNO MalAinp Addrssa• ` <br /> PO Box B6 Pertnit nurr�bs�: / 7 <br /> Crystal Bay,MN 55323�Upg8 Date roeeived: - -� <br /> � ; SGeat Aa4y�ess: Recaivsd by; � <br /> � G n50 Ke98y P.rkw.y �7�.S� <br /> �KFSNOA�' ��,MN 55358 Plan reviewtse: <br /> Main: 952-249-�800 Fax: 952-249-4818 v�N y d oro� Tofal Fee: ��C� .,� Q l� <br /> This ePplication tortn must be completed'n(ull and a11 required infortnaUon must be wbmined, v <br /> GENERAL INFORMA71ptd: Incompleb app�icaBons will be retumed_ r �y� rinq � <br /> � (� • <br /> Job 31te Addresa: J �J �cti 5 C�i �� ` /�. ' f <br /> Will thls be a Puade of Homes,Remodelers S►iowcase Home or other Display No� � J�� /v <br /> nY�+.a spscid mrit Prmif k nquind w�P o l i a O�p a rt m e n t w M C l ty C o un d/approvd 80 da Y@ f <br /> +e4 u h e d uM�st app�6cent d�na�ahaha+uRkkrM on-alfs Pe�+n9 b avapebfe. Non-ri A�'fo t�s evenl. Shuffk bus+wics wRf bs <br /> COMTRACTOR I APPLlCANT INFORMATION; P1""��s`'°^h w�l7notbr a,7owsd, <br /> Name: <br /> State Licenee N <br /> Lead Certifk.ation Number: Expiratlon Dafe: <br /> (1'��wor*on homet thn w�A���p�or to 1978 �PRation Date: <br /> Phona: (ceA) <br /> Mailinp Address: {otfice) <br /> CoMact Person: �dY� ZIP: <br /> Emall and/or Fax: APPI�nt is: Contractor / Nomeowner �c�N� <br /> PROPERTY pWNER INFORINATI : <br /> Mame �1 ' / �.���SS'1 ' ZT'i�D <br /> Phone(dAy): 'Z.1 �r-�l <br /> Aa��B: — �•y � t'T l�.l <br /> Email and/or Fax: Cc co City: ���a.a ZJP: ��3'j� <br /> 4., <br /> PROJECT INFORMATtON: Overat! 'ect des�r' � <br /> Typa of Proj�ek <br /> ���°) ❑Remodel ❑Fke Damape Any MCVW nvlew�also nqulre <br /> ❑Re-roof,nphalt P�rmkr. <br /> ❑Rep�ir ���p�98 Min�rohahe Creek Waferehed Oistrio((►�ICyyp) <br /> ❑Re-rmf.eadar ❑Reatoratlon ❑Waler Damape 18202 MinneloMc�Blvd <br /> ❑Rs-ropf.ofMr(sp�esy� ❑Sidinp ❑py�r(�pedfy) �°�en'� �391 <br /> Phona: 952-471-OSgp , ) <br /> dow(e) : 652-471-0662 I/ <br /> Eatlmated Conatruetio�Valwtlo�of Project(exelu�ne land) j /�I� <br /> APPUCANT AGKNOWLEDGElWENT; <br /> • �9f°°s�°ProMde NI informalian requfred or requested by the BuNdinp Departmen� <br /> • CeNfiea Ciat the iMom�eyo�a�ppp��������o the Dest ot hia/her knwdedpe. Ths appCqM�nizes that they are <br /> kcl i un���tu��a��ete appBptton beiny awero that upon fallure to do so,the staff has no���bW b <br /> f° con+pete; <br /> • 9ortro or all of Ihs h�ort�yon yut you aro a�ked tO p�vlde on Ihis aPP�atien b classifbd by 8tate law as either private or <br /> ��e��. P�B1e����°d°^wh��h pm�eraly annot be piven to ihe piblic bul cen be piven to the aubjeq p{��te. <br /> ��������On^�HO^���h O��sYy annot be pNen b ekher Ihs p�61k or Iha subjeU c{Iha data. Our purpcse and <br /> aMended we of thia informalion is to armuallyr update our rscotds and nwrds of ot►br pove���l��poa roqu{red py I�w. If <br /> a+rshns b s 1 icaUon m� not be isy��. <br /> APP��ent's Si�atu , `'�„_ <br /> Date: � l <br /> ow�era sbnsr�e: Z -' /y <br /> Date: _ (��_ <br /> tasi updqed:o�oerzm a --T-- <br /> `�t� � � � <br />