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! � <br /> � �j'�/ O� 4rOi10 <br /> Building Permit Application for Maintenance 1 Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> MailingAddress: Permit riumber: � 5/� <br /> �s PO Box BB r� <br /> p�a�`yO Crystal Bay, MN 55323-0466 Date received: /- "/-J <br /> sr�t aaa��: R�N�d�y: <br /> � G� 2�150 Kelley Paricway Plan re�iew fee: — , <br /> t,� o�. Orono, MN 55358 <br /> Tota��ee: � % 9 a• ?y� <br /> � Main: 952-249-4600 Fax: 952-248-�$16 www.ci nd.m <br /> This application form must be completed in full and a!E required informatlon must be submitted. <br /> Incorr►plet�appliCations wlll b�returned. (Please p�'nf) <br /> C3ENERAL 1NFORAAATION: �� 'Q � � ��p�S��Q i�� '� • <br /> Job Site Address: ► <br /> WI�1 this be a Parade af Horoes, Remodelers Sh case Hflm�or othtr�isplay Hom�? Yes No <br /> K yes,e ap�cFel event perm�t!s required with Polfce Depannle►►t and Clty Cound!approvsl 60 days pr�or fo the event- Shuetle bus serv'rce wAl be <br /> roqul�d unle8s appJicant demortsL�fes suf�rcient onsite pafldng is evalFabJs. No»�ermitted eVer►ts wrl!rrot be allowed. <br /> CON7RACT�R/APPLkCANT lN�ORMATIdN: <br /> Name� 'l t � � �'��� <br /> State License# G�3oq 3 <br /> Expiration Date: ',5 31 <br /> Lead Cert'rficatfon Number: � � a �$ Expirat9on Date� �f�s ._ <br /> (for worrc on homes ltrat ware consdv�tad Pr3or to i97� (cell) <br /> Phone: (c51� a7 —�0`�- �c {of�ce) <br /> Mailing Address: �q ••C,•• W�.S� C�tY= v:l1e ZIP: SS <br /> Cantact Person: Applicant is: ntra / Homeowner (ClrcEu OnoJ <br /> Email and/or�ax: <br /> PROPERTY 4WNER INFORMAT1dN: <br /> Name: G�v( �, � � � <br /> Phone(day): ,S �-- Q <br /> Address: ' S• City: Zlp' <br /> Email and/or Fax <br /> PROJECT 1NFORMATION: <br /> ry��Pr��@�. Any earth movemeM may requ�r� <br /> MCWD rev�ew&permits: <br /> �p�r��� ❑Remod�l ❑Fire Damage �yinttehaha Creek Watershed Dlstnct(MCWD) <br /> � Re-roof.esphalt 0 Repair ❑Storm Dame$e 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑Re�roof,tedar C] Restoretion ❑Water Damage p}���ne: 852-471-0590 <br /> �Re-roof.other(spec�ry} ❑Siding �4ther.(specify) Fax: 95Z�71-0682 <br /> .min hahacre� <br /> ❑Wlndow(s) <br /> Overall Pro ect Desc�iption: a� � <br /> Estimatsd Construction Valuatlon of Pro ec#(exeludin land) $ 3'�--' <br /> A,PPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information requlred Or requested by the BuElding I�epartment; <br /> . Certififies thal the int�srmatian auppfled is true and correct to the best of his/her knowledge. The applicant recagnizes that they <br /> r <br /> are solely responsible for submitting a complete appllcaiion being aware thai up4n faifur�tp do so, the staff has no al#�mat�ve <br /> but to reject It until it ls complete; <br /> + Some ar all Of the infqrrnatlon that you ara asked to provid� on thts applicatton is classfied by StBte law as 8ither private or <br /> �dr�ftdenti&I- Privafie data is information wttich ges�rally cannat be given to the publlc buf Can be given t�o tfie subJect of the <br /> data. Gonfldential data is information whEch ganerally cannot be given to either the publio or th� subJact of the data_ Our <br /> purpose and intended use of this informat�on is to annual{y update our records and r�cords of other govemmentai agendes <br /> re uired b 4aw. If u refuse ta su 1 the information,the a Iication ma noi be issued. <br /> Aonlicant's Sianature: �/'~''� �a�: ����'�� <br />