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Nou B3 Zell 18:58:89 -> +952Z494616 Life Time Fitness FC Page 8eZ
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<br /> � Building`P�rmit Appli�a#ion for Maintenance / f��n�avafii�n . .
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<br /> This�ppllcation fo�m must t�e complet�d in f�dl �nd all tequired information must.bP submitied.�
<br /> Incomplet�applfcatlons wfll be returned. (Please print)
<br /> � � GENERAL 1NFORMATIC?N:
<br /> Jofa Sil�Address: _�,�;�,�'..,� �- ,..:��,.���� �4'�: ,,r � ;���✓,�'U ,.�"�"�!� ��,r7�_ ��,�,�.
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<br /> Will this be a I��r�de of Homes, Remod�l�r��otnrcas�Home oP other isplay Home7 ��Y�s ���No
<br /> tl'yrrs,a�spr?cit�l eve��t permiP t�r�quii�ax�wi(1i F'o/ir..e tJr�p�artinenC�r�d Cily Co�.mr.il����i���v�:�l Fi0 d�ys prinr ts>PNp evP�tt. ahUttle bus e,eivic�iNill ne
<br /> ' i•Qeruri'�c9 unless�pPllc�nr dsmar�fr.atc�,�a s;i.,lfir,�enf on-:,itr pr�rkin�;�s tiV701/.:d'JIf1. NUllMpar»lltlsd wvonls will ricat b�arlpwr.•�r1.
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<br /> ' CONTRACTOR/APPLIC NT IMFOR AT,ION:
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<br /> �.x ir�tion DaC� 1
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<br /> l,ead Certification NumbFr; �x�iration Date:
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<br /> (fur work on homea that ware consCructed prfor to 9878
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<br /> Contact Per�on: Applicant is�. Contractar / HomeOWnet �Ctrcle 0ne) '
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<br /> PROPERTY OWN�R I,�IFORMAT�N:
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<br /> Addr�ss: ,,,� �°",.r.�.�'.�.: �✓'��;_�'�. ............. �tY,;.,:�,,.��_�_...�:.�w�_.. ZIP:_c.'�,,�._._,T,..,,_�mm.,..,..
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<br /> PROJECT INFORMA Ohl: �
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<br /> Type of Project: Any earth movement may reyuf�o
<br /> �l�oor& MCWD re�f�w&pmrmfts;
<br /> ( ) C� Rerrindel L Fire f���iY�i�r�e
<br /> Minneh�ha Creak Watershed f�istrict(MCWL"�) -��
<br /> ❑Re-roof,asphalt � Repair �St�rn1 l7amac��. 18202 Minnatonka F31vd
<br /> � he-roof, cedar b Restoration L�Water Damag� p��phaven. MN 55391
<br /> Phone; 952-471-05�0
<br /> O F��raof, otho�(apoclfyj . []Sidin9 U Oth�:r;(specify) Fax.� 952-4�1•O�i82 �:,�
<br /> ,,,,,_ . ❑.Window(s) �.�.._,.�. +tivww.minnehahacreck.�rg
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<br /> �. Oveiall Project Descrlptlon: �
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<br /> Estimatcad Constructlon Valuation of Pro act oxcludin land ' °. ��•�WWW����.W
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<br /> • ^Agreesto prov�de�II inf�n�i�tiM�quired ar requested by _����'M,,,V�y��VW������ �
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<br /> APPLICAN7 ACKNOWLE,----.._....._.._.�....,;�., .._..,._,.— ._.,,......_..............__�,�._._ �..
<br /> tho Building C)epartment;
<br /> , • Certifiea tlial th0 inic�r�rn�tion suppliUd Is true�nci correct to the best of hislher knowledge:` Th� applicent recogr�lzes that they �.
<br /> ar�solely responsl�,le for submihing a carnplete application being �ware that upon f�ilure to c�o Eo, the str�ff has no alternative
<br /> but to reject ik until it'is complp�e;
<br /> • . 5am� nr all of the in��rm�tion th�t you are asked to pravidca on thi� application is classified by St�te law as either privat.o or
<br /> canfidential. Prlvate data is iniarm�tian which generally cannc�t be giver� to tha public but oan be given to th� suhject of tlia �
<br /> data. COnfid�ntial data is infarmatlan Wriich gen�rally car7not be glven to either#h� ,public or the subject of the datr�.. Dur
<br /> , ` nurpose and intandad us� of this inform�tion is to annu�lly updata our rnrorrfs �ncl recx7rds of'other g�v�mmental agencies
<br /> ` recjwired�:law,___If,�rau,retuse to s Ihc�mform�afion the a licai�an ma ric�t be is�ued. �
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<br /> Applfcant`s SignAture: C���'� IJate: r.� `
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<br /> f_oAt Updat�d: 0�-0;�-20'11
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