|
v��x w� v� v� �v
<br /> Building Permi� Application for Maintenance i Replacement 1 Remadel — Residentiai ONLY
<br /> �, �A, � t`� r ' :.t � ^� s.
<br /> ¢;.�;. +a"usf'����<:ty'' , ":�M��.l+„^;�, �at'd$s' ,. �,.. ,'r` 'k.�"�.v. - ��$,� ���h��p�a.F$`:��.xo ;4,�'',,. r•�aJ'�i�x�w,��4s
<br /> .'r _ �`' � Maiting Address: Perrnit number: 2��
<br /> r`���-�� ��� PO Box 66 �
<br /> � '� Crystai Bay, MN 55323-QO '� Date received: �_�.0� �
<br /> � i Streer Add��ess �1� Received by: _��� _
<br /> ��i �,�� 2750 Kailey Parkway 1,�� r Pfan review fee: e 6�-C'�
<br /> ` � `�' Orono,MN 55356 � � (■��
<br /> �'fA'YCSYlC>�`'ti-`' — /
<br /> '�_.__.�� ; Total Fee: / � <• �ry
<br /> Main: 852-249-Q800 Fax: 952-249-�F616 �wvv,cl_or+anc�_rr�,ri�� �J
<br /> � This appfication form must be completed �n fufl and ail required information must be sub�iitted.
<br /> Incamplete appiications will be returned. (Please pri��t)
<br /> GENERAL INFORMATION: .� � �! tF �
<br /> Job Sife Address: �.� A , ; �;,r__ --
<br /> WiEI this be a Parade of Homes, Rem ' ers Showcase Home or othe�Display Home? Yes No
<br /> lf yes, a specia/event perrn+f�s rsqurred wrfn Police Department arxt Crfy Gounul approvat 60 days prror fo the event. ShuttJe bus se ice wiR be
<br /> repuir$d unless applicar►t demonsirates suffic�ent on-site parking rs available. lVon-permitfed events wrG nof be aMowed.
<br /> CONTRACTOR/APPLICANT iNFORI�ATION:
<br /> Name: _�����`,����`� ��.��� �.,;,<<:.,��'4��-�vw�
<br /> Expiratian Daie: 3.-7�f �`��
<br /> '"�� 1 1'�[.�( - �-` .�v'JU
<br /> �,' 1�} a�`��;; _. Expiration Date: , �7�;,.�
<br /> Lead Certification Ni,mber: ;�j�� _�.1 .��.�.�,-- - ----__ __.__ --- -- .�-�,,-,��
<br /> (for work or+hames that were constructed prior to 9978 '�
<br /> Phone: {cefl) �,,�-;�„ �7�� ��,��'� (office)
<br /> Mai�ing Address: 1 iCl`i I`��f rf �-: �� /'li�:. City��-'�.,,�,y �";�;;t ZIP: ��`'�,,�t
<br /> Contact Person: �`��� ��,��,,.� Applicant is: + Cont�H meowner �ci.de o�>
<br /> Email and/or�ax: �.r.��.�,,� t'��,�. `-�' f,,.�.1�,� l , t„-..�
<br /> PROPERTY OWNER INFORMATIt?N:
<br /> Name: �=;r-z.,: � ��<<.�;� ^1�;.L.�(�.:,,z
<br /> Phone(day}: ""1�._ �l_�^_`'�_���..�____.___ ; �
<br /> Address: � ��;�,t �- ���t.� s,� _ City: �"`:j �,.;a�,� ZIP: `�"?� ,��(�,
<br /> �maif andlor Fax: ,,fi a:r;z ,�� ��r .�.�� C�t_��»�.�a�s �-,.:-,
<br /> PROJECT iNFORMATION; Overall project description: ��r,��t��rv, �' �'�tt; j-�t.;�_ � :-�; , ;��,..���t�
<br /> ' Type o#Project: - � y�W��� �Any earth movement may atso require
<br /> ? ❑ Door(s) (�Remodel ❑ Fire Damage � �CWD review 8�permlts:
<br /> ❑ Re-roof,asphalt `�[] Repair ❑Storm Damage � Minnehaha Creek Watershed District(MCWD)
<br /> 15320 Minnetonka Blvd
<br /> ❑ Re-rooP,cedar ❑ RestoraUon ❑Wat�r Damage Minnetonka,MN 55345
<br /> ❑ Re-roaf,other{speciy) 0 Siding ❑Other:{specify} � Phone: 952-471-0590
<br /> �ax: 952�t71-0682
<br /> ❑ONindow(s) � ',,E � ,.� _���:r?
<br /> Estimated Construction Valuation of Project(exciuding land} � ..�`t(� ,
<br /> APPLICANT ACKNOWLEDGfMENT:
<br /> _ _ ___ �,
<br /> i • Agrees to provide all informatian required or requssled by#he 8uilding Oepartment; �
<br /> • Certifies that the informatian supplied is true and correct ta the b�st of his/her knowledge. The appiicant recognizes that they are I
<br /> � solely responsible for submitting a complete application being aware that upan failure to do so,the staff has no altemative but to E
<br /> reject it until it is comptete; 1
<br /> I
<br /> , • Some or all of the information that you are asked to provide on this application is classified by Siate Vaw as either private ar i
<br /> canfidenhal. Private data is information which generally cannot be given tb the pub��c but caR be given to the subtect of the data.
<br /> Confidential data is information which ger�erally cannot be give� to either the pub(ic or the subject of the data. Our purpose and
<br /> fntended use o#this information is to nnua{ly update our records and records of other governmental agencies required by law. tf
<br /> � you refuse to su i the infoi i .��e� licatipn m�not be issued. --_--_-- -_ -- ----�-___--_.___
<br /> Applicant's Signa#ure: � � Date: /�,2—�tp _
<br /> Owner's Signature: �� Date: =3� �T� �
<br /> ��v� �l'" Z �
<br /> � � �
<br />
|