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� Building Pe��t qpp��cation for MainteOnan ce/ Re lace <br /> (No structural expansion. Only windows, doors,s;d;ngm ent/Renovation <br /> �ON M��D Addrasa: <br /> � ��I � Perrnft numbsr: aQ�!�,r� ��� <br /> 9ay,MN 55323-ppgg Date rocelved; 7 <br /> s� ; ShsetAdWess: R�� � / �� <br /> t G 2730 KsBey Parkwa �: <br /> �'�FS H OR�' <br /> Oraw,MN 55358 y P��s�tss: � <br /> Maln: 952-249-�gpp Fax: 952-249-4818 v�d.aono mn��= TOw Fee: /� L� <br /> Th�ePP��a�ion form must be completed in full and ali �� r.:JCJ <br /> Incomplets appUcaBons will be retumuired�fortnadon must be s�bmitted. <br /> GENERqL INFORMAT10N; �. e�(�ease nnt) <br /> ��$��A�..�,: � � c�.5 <<, �- , �J � � �J <br /> 1MII this be a Parade of Homes,Remodelers ghowcas�Ho�a o�er D� I Home? J�� <br /> n�.a�r m�Pamit k requrnd w�Polior $P aY Yes <br /> ^s4u�d w�fsra appf(cant d�rncnah�ha aP�+na+t�rM C!ty Counci/approvd BO ds!'a A�fo!hs sront Shutfb bus <br /> +�IRCbr#on-alts PB�i'�9 b avalleble. Non-p�m�ittsd sronh wf0 not b�Nkwsd. wiil bs <br /> CONTRACTnR I APPLICANT INFORMATIpN: <br /> Name: <br /> State License# <br /> Lead Certiflcatip�Number: ExPi►ation Dete: <br /> �r�on homas thn wM c�n��p�r to l97d �PRation Date: <br /> Phona: (cell) <br /> MeiUnp Address: I�ce) <br /> Contad Person: ��� Z1P: <br /> Emall endlor Fax: Applk;ant is: Contractor / Homeowr�er �c��oN o�.� <br /> PROPERTY pWNER INFORMATI : <br /> Name� • v. r <br /> Phone{day): �..! ]3 G sr-� � <br /> Addf9SS: ( T ,n / ----� <br /> Email and/or pax; C` � /l•/ City: ���� '— <br /> �, va: ��i`.3�� <br /> PRWECT INFORMATION: OveraA 'ect desa' ' <br /> TYPQ ot Ptoj�eh <br /> ��0°<<a) ❑Remodsl Any earth movem��m�y tlw nqWre <br /> ❑Raraol,saphalt ❑Fhe Damape MCWD nvlew 3 p�rmkr. <br /> ❑Repatr ❑Slorm�amege Minrrohaha Croek Watenhed�istrid(MCVyp) <br /> ❑Rsroof,eadar ❑Reatoratlon ❑Waler DameQe 18202 Minneta*a Blvd <br /> ❑R°�f0°�,°�°��� ❑Sidinp �seP�en,MN 58391 <br /> ❑�r(sP�i(yI Phone: 952-47t-05gp <br /> dovv(s) : 852-471-0682 <br /> Estlmated Conatruetio�Valuatlon of Project(exciuding land) : �� <br /> APPLICAN7 ACKNOWLEpGEME�: <br /> • Aprees to pro„ide�����ion roqulred or requeated by}l�g�pd��Deparfinenk <br /> • Certifies Iha�the iMormeyon supp�a�s���to the best of hislher knawledye. T�applicaM recogrriiss the�thq,are <br /> sdsy msponatbb far aubmitlirp a oomplets apptlntion beinp awaro lhat upon/aflure to do so,ihe alaff has no albmathro but b <br /> roJect It untll it Is cwnpkta; <br /> • 9oms or all of Ih�bNortnaYoimo►maYon whlch���Ovlde on Ihia aPP�ation h claul(bd by 8t�le Iaw as either prfvate or <br /> ��e��. P�a���� �e��y annot be piven to 1he publk but can be plven to tha <br /> Confid�ndal data is kilomw�p��Iq� enera annot be iven b Mthsr Ihe blk or ths su6 �{�do���°�Ws date. <br /> intended we of Ihis informeUon is lo aru�ual pu 9 P�+ Jed <br /> a+rsfuse b s 1 t h� Pdete our rocords end ncords of oHxr gcvemr��l P�se and <br /> icaUon ma not be issued. a9enaes roquked by law. H <br /> APP��anPs Si�ahu . `�_ <br /> Date: � L <br /> owners siynsture: M /� <br /> ta.�updqea:oaroerlo�a Dafe: C'r� Z ij <br /> ``-��' �l/�J � C <br /> _..J . <br /> I <br />