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JUN-2-2016 07:43 FROM:TREBILFOUNDATION SYS 3205938720 T0:1952z494616 P.1 <br /> , � <br /> City of Urono <br /> Building Permit Appl�cation for Maintenance / Replacem�nt/ Remodel — Residential QNLY <br /> (i.e. windows, doors, s➢ding, r�WrQof, etc. —NO STRUCTURAL EXPANSION) <br /> Mailinq Add�ss: P�rmik number° -✓ .- ',.: <br /> �O�Q Cry sal Bay,MN 55323-006B �,�. Date received: �� ' � <br /> streer Addrass: �f <br /> y Recelvee by: '—� <br /> � � 2750 KeAe Parkwa ' <br /> y,� � Y Y � Plan review fee: --� <br /> t,� �,� Urono, MN 55356 ---- . . , - _ <br /> k�s�`O� TOtel Fee' � ��� � <br /> Main: 952-249-4800 Fax: 862-249�F1G www.ci.crono mn.us <br /> 7his application form must be Gompfeted In full and sll required Infprm8tfpn mu5t be submitted. <br /> Incomplete applications will ba returned. (Please print) <br /> GENERAL INFQRMATIQN: r " �l <br /> Job Site Address: �� �� ��G�,�A �� �Q� �Q �/V <br /> Wil!this be a Paredo of Homas, Ramodeler�Showcas�Home or othQr Dis lay Hom Yes No <br /> N yea,a speclel event perm;!is,dqu;red with Pplic�Department and Ciry Council approva!60 days prror to the evont. Shuttla bus servire witl be <br /> ietluin9d unless eppliCant dempnstrates sufrrCient on.site pdrlcinq is available- Non.pennifted evonfS wil!nOt be allowed. <br /> CONTRACTaR/AP I.IGANT l �O 7 - n <br /> Name: S� � ��t� �S-� £'D�c,.�Sl j'!�t <br /> $#ate I�iGense� ' �xpira#ion p�te: _. �0 <br /> Laad Certification Number: b � � Expir�tivn Date: <br /> (for work on homOs fhaf wore conatructed prlor ta 1978 <br /> Phone: cell) � (office') <br /> . . <br /> Mailing Address: , , '� G�, City: ZIP: �� <br /> Cpntack PQr&On: {�,�� AppliC t ig: pntraC Hpmepwner �c�rcie one� <br /> �mail and/or Fax: ��,. S'Q. Gt..S�Q/YI2.k �' �f�7 � �aZ d <br /> . <br /> PRQPERTY OWh1E NFO�q A7 O : � <br /> Name: �G�17 L " _ 6G(�S'� °� /�a,!(Ljl�/ �"(�.L�'�/�'�Q.(�-l� <br /> - - , <br /> Phone(day): � <br /> Address: Y/ �1 `�.�.� CitY:�j �IP� �5�,�5ro <br /> Em2if�nd/or Fax' <br /> � ��.s'lCc��./u� Y��AI� <br /> PROJ�CT INFORMATION: Overal� ro'act descri tion: ����� ����� �u� <br /> Type of ProJect: i Any oarth movoment may al�o wequlro <br /> ❑Door(s) Q Ftemoda� ❑Fire Damage ���ND roviow&pormits: <br /> ❑R6-ro0f,as halt Re 8ir Minnehana Cr�ek watershed Oistrict(MCwD) <br /> p � p ❑Storm Damege 15320 Minngtonka Bfvd <br /> �Re-roof,cedar ❑RBStprdtion ❑Water�amage Minnetonka, MN 55345 <br /> ❑ Re-rqpf,Othor(�peoity) ❑Siding ❑Other: (specify) Phone: 952-471-0590 <br /> Fex: 952-471-0682 <br /> Q Windpw(s) www,minnehah»creek,ara <br /> Est�mated Construction Valuation of Project(exctuding land) $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to provide au fnformation required or requested by the Building Aepartment; <br /> • Certffies that the inf4rmation Buppliad is true and correct to tha best of his/her knowledga. The applicant recagnizes tnai tney are <br /> sofely responsible fpr submittinq a Cpmplete apqliCation b�ing aware that upon failure to do so, the staff has no atternative but to <br /> reject it until It Is Gomplete; ', <br /> + Some or all pf the information that you �ro askod to provide on tnis eppHcatipn is Gassified by State 18w as eitner private or <br /> Canfidential. Private data is infprmation which 9enerally cannot be given to fhe public but can be glven to the subjeCt of the datp. <br /> Gonfidential data is information which generally cannpt be given to either the public ar the subject of the data. Our purposa and <br /> intended use of khis intormation is to ann 3y update our r�cords and records of other governmental agencfes requlred by law. It <br /> ou refuse to su I i formation th licati ma n4t be isSued. <br /> Applicant's Signature: p���: � � a D�G <br /> Owner'� Signature: Date: <br /> Ldst UpdBted:January 2d1fi � � /� <br /> �f''�� � [ <br /> �i��% l <br />