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esui�aing �ermit Appli��#ion for MaintenanGe 1 Renov�tion <br /> (windows, doors, siding, re-�oof, etc.) <br /> MaiGng Add�ss: <br /> PQ Box�6 <br /> Crystaf Bay,MN 55323-0068 ermit number: Z D I b — DO 5� <br /> sr,�oraaaress: �`j l I_I b <br /> /��� 2750 Kellay Parkway Dat�receivetl: <br /> Qg,���, Orono, MN 55356 <br /> �., � Received by: <br /> � Fax: 952�249-4618 �.r�orono m2us <br /> lan review fee; <br /> v���qt�0�'�� <br /> ��.::-.-��/ <br /> Main: 952-249-4600 olal Fee: / u <br /> l /J�' • � �� <br /> This appiication f�orm must be completed in full and all required information must b�submitted. <br /> Incomplete appllcati�na will be returned. (Please print) <br /> G�NERAL INFORMATIpN: � ,/'� � ` 1n���� ��D�O �� ���� <br /> Job Slte Addrese: `�� ���J � <br /> Will ti�is be a Parade of Womes, Remodeler� how�ase Hpme or oth�r Display H ma? Yss No <br /> �f yes,a speCie�event permit�s requimd wUh PolJc�D�ppnrrrenr snp CJty Cpu�!!�pprpve180 deys p�io�fo Ihd yvgnL $huttlb bus sdrvk'�wql be <br /> rnquJrgd unl�sy sppJlCpnt dampp�}�t,ps sufl5cient onslte purivnfl ia availablo, Non.permfttod vuvnts will not bo Affowed. <br /> CONTRACTpR I A�P.�.ICANT INFORyIA I��� <br /> Name: (� �hi S�rar�'k.z`s <br /> State License# xp�r�k�On 8te: � � <br /> Lead Certification Number: ,2 Expiration Date: ,, �� <br /> (for work on hem�s thai ware GQn$t�ucte p or to 978 <br /> Phone� .�� r" - ��..�:i �� �:;;- <br /> . {office) (cell) <br /> Mai►ing Address: = � C � � , � � j' City. l�:'i i,,.;��� ZI P: �- �����', <br /> Contact Person: ` � ' ` � - '- <br /> AppliC�nt is: ContraCtor / Homeowner � �ct�c�a one) <br /> Email and/or <br /> �vame: �l dh t,..,'f(�1�l1/ <br /> Phane(daY)= <br /> Address: City; �Of1 D ��P; ��3�'`i <br /> �mail and/Or Fax <br /> PROJEC7 INFORMATiON: <br /> Type of ProJect: Any OaRh movement may roqulro <br /> ❑Doar s ❑Remodel MCWD ravfew�pertnits: <br /> ( ) Cl Fire Damage Minn�h8ha Crgek Wstgrshed DiStriCi(MCWD) <br /> 0 Re-roof,aaphalt ❑ Repair ❑Stotm Dama�e 18202 Minnetonka Blvd <br /> Ro-roof,aodar Deephaven,MN 55391 <br /> ❑ [,�Reatoration �Water Qamago <br /> Phone: 952�71-0590 <br /> C7 Re-roof,other(apeclfyr) �] Siding ❑Other:(speGty) Fax= 952-471-q682 <br /> C.��ndaw(s) www.minnehahacreek.pri] <br /> Overall Pro ect Deecrlptipn: a g� O �( p, p�U • ,�" /� , <br /> �stlmated Constructlpn Valustfon of Pre ect(excludin land S DO °° '�L <br /> APPLiCANT ACKNOWL�DGEMEN7: <br /> p Agroes to prpvide all infprmatipn required or requasteC by the 6ullding DepaRment; <br /> p Certlfies that the inUormation supplied is true and carrect to the best of his/her knowledga. The applicant recognize5 that they are <br /> sate�y responsible for submitting a complete application being aware that upon failure tv dp so,the staff has no altemative but to <br /> reject it until ft is complete; <br /> ❑ �ome er all at th� information that you are asked to provfde on thi9 application is classified by State law as e�ther privafe or <br /> confid�ntial. Private data is lnformatlon wniCh g6ner�lly C&nnot be given ta tha public but can be given to the subject of tha data. <br /> Con�identio�l data is informatior�which genera►ly Cennot be given to eitlter tite public or ine subj9ct of the dat�. Our pur'pbse antl <br /> intanded use of thls in1brmetlon Is to 8nnu811y updatE�Qur reCorCEs and reCords of ather govemmental egencias required by I�w. If <br /> y0u rafuse to sup the inforrriation,th�� li�tipn may not ba issu . <br /> Appli�nk's Signatur . �1','`,✓ ` � Date: ��1/t �'�, a a�G <br />