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<br /> G1� �F �R�No �UiLDliVGp{� �F �RONO
<br /> ERIViIT Qpp�ICATIOt�
<br /> FOR IVEW STRUCTURES OR ADDITIONS
<br /> ��� fviai/ing Addrbss,
<br /> ��,� '\ PO Box 6fi I Permit number. �� y -D�l-f �u �
<br /> , Crystal Day,NiN 55323-OQ66 -- _�` �'�-�
<br /> ; I Date received: I�LO�l4_
<br /> ' "�\� � Slreel Rddress:' ( Received by �.� - -+
<br /> �'��,,r� �, 2756 Kelley Parkwa -^ / -—+- __ ---- ,_
<br /> �;t sri����� � Orono,IvIN 55350 � �'" I C�-���� Plan re4iev,�f�e: �� 3q' �
<br /> -(vtain: 952-249-460G Fax: 952-249-4616 - _ _ __.____ _____.. ' _ '�(t�-(;/4/�
<br /> Total F�,
<br /> — - ';�,,.c,.oror.�����:.us �c�.,,,��
<br /> This appiication form must be completed�n fuil and all required informati�{�t h���m���$d�� �•(�'�
<br /> Incomp�pte applications wilt be returned. (P/e�se prrniJ �`� , "L4 ` ( ��-( ,�� k
<br /> GENERAL lNFORMATION: ����
<br /> Job Site Address: �
<br /> _l_Ly—�.Lf��_;_ ___L{,1��:.<- �, ,�
<br /> UVill this be a Parade of Homes. Remodeler$Showcase Home or�o h r Display Home7 Yes �(;=�1,.��,��
<br /> T_u1�2���-��,���5�
<br /> ��yes �sperol E;��;���;_ff7;;�rs requir�U tvi�h P�I;�v Dep.trrment a„�C;�y Councd�AA����a�6U days prror�d tne event Sriitt/e Gus ser✓ice:vil�uc O
<br /> r�rc7,;ired��nless���r�l,c;u�t�c;�•rr��n.;'r�lcs sulfrcienf on-s�tr,parkinq is avarlable. Non-permitted evcnls�vrN no;bs allovted.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name�
<br /> State License# ��'���� ������ �J)�(, ._L�L.
<br /> C�C.�_(�L`jLG>> _ _----
<br /> _- _ _
<br /> Phone: ---------__..
<br /> ---- _ Expiration Date: 3 . �-
<br /> _�L��c Z�_2'Jv �,1f--.- office --_31_ Z�i�
<br /> Mailing Address: �, -----__1_�___ -____.
<br /> r-��s -----
<br /> Contact Person: :.� --------____ Cit : - -
<br /> �`_`-�--- - ---Y�/[�"�L-'�v..r�ZIP_�'S�� �-`
<br /> Email and/or Fax. .. - -- _ Applicant is: rontr / � --
<br /> �.,/b�L�'1��c�c�.q`--x Q�1����-/�� �� Hom�owner ico-�m o�o�
<br /> "Y'/-u1 �—_-�..�)l� _�_�_Q�---�C�--.7_L_�.�5....7^_���' .
<br /> PROPERTY OWNER INFORMATION: __LZ _
<br /> Name: ' '
<br /> Phone(day): ���� ��'�
<br /> •-1�_ ---��'�----
<br /> , ., . __ -- _--_.
<br /> Aodress `_ _ � �v � =- ' �_�.- __ — - ----- __--
<br /> JL/Cr�� C.+��� �,,� vUji-�'��t'r.rr _
<br /> Er�ail andlor Fax _ ---- CitY_�/C41�,�; ZIP. 5�3c•
<br /> --- - _ — - ----�--=-/�_
<br /> ARCHITECT!ENGINEER INFORMATION: � � �� -
<br /> Name:
<br /> Phone(day): — - -- -- _ -_
<br /> Address: ---— ,
<br /> Email and/or Fax _ Citv� ZIP:
<br /> _PROJECT INFORMATION: Description of pro ect
<br /> �•Type of Project I 2, proposed Use
<br /> i 3,Structure Type i 4. Sewage Disposal&1
<br /> I ❑New Construction mgle Famil Water Su
<br /> i �"Addition y with Residence pP�y
<br /> i !J Accessory Building �ttached garage �Garage!Accessor� Bld �
<br /> I ❑Relocation ❑ Single Family with ❑Der.k � g' � ❑Public Sewer
<br /> I ❑Other.(specify) detached garage ❑Office/Commercial �
<br /> � , []Pdiultip(e Family/Condo ' ❑ P�ivate Sewer
<br /> ' ❑Pubtic ❑warehouse
<br /> 'Any earth movement may also require ❑Storage �
<br /> i MCWD review&permits. �Commercial ❑Olher(speci(y} , ❑�'��blic Water
<br /> ❑Industria( �
<br /> IMinnehaha Creek W��ersl,ed Distric;(MCWp) I
<br /> 1a202 MinnelonKa Blvd ❑Other.(specify) ❑Private W�p
<br /> Deephav�n,fvlN 5539� i
<br /> Phonc: 952-471-0590
<br /> F�:c 952-471-0682
<br /> .r:,:•riirnenahac�aak orn i �
<br /> �:�_�.w,...._.,.�v�.:..�,_
<br /> ____�___—
<br /> —--
<br /> Estimated Construction Valuation (excluciing Iand) _-�� r
<br /> s y.f��7� �- --- - --
<br />
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