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J��r� 24 �� 10:37 Conr�ie �avid 763-783-1811 p.1 <br /> ► <br /> � C�ty of Qrono <br /> , <br /> B ild�ng Permifi A.pp�ication for �nternal UVork <br /> �windows, d��ors, sid�ng, re-roof, etc.y <br /> ��� Mailrng Addres;: ��IO -�O� � <br /> ��� � PO Box 66 Permit number: <br /> V �. <br /> � �� I Crysta�Bay, MN 55323-0066 Dale received: / Z /! <br /> ,� ��Z; » _ <br /> ��, : ��: h) S�reetAdd�ss: ReceNed by: <br /> '�'t$� � o ���� 2750 Kelley Parlcway Plan reviewiee: <br /> �� Qrono, MN 55356 <br /> Total Fee: � �� � , � <br /> Main: 952-249-4600 Fax: 952-249-4i1 6 w w w.c i.o r o rt o.m n.u s <br /> This app�ication foRn must be compleled in full and all required irrFormation must b submitted. <br /> I camplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: � <br /> Jo Site Address: �5 ; ����y �' ' <br /> WII this be a Pa�ade of Hame , Remodelers Sriowcase Home o�other Display Home? Yes <br /> I yes, a specia�event permiF is requ� with Police Departm�nt and Cit Council a rovaf 60 da s NO <br />�' � r qufred un/ess applicant demonstrafes sufrrcien on-sife pa�ng is avai able. Non perrni�ed events willtnot be allowed.eNice wiU 6e <br /> CONTRQCT !APPLICANT I FORMATION• <br /> Name: T "lP.� YGc��k: /�p��N �c. <br /> State License# p � �-r <br /> �cpiration Date: �-3/- �,�� <br /> Phone: C�S/- - 7� � office � -J �-!/2l <br /> Mailing Address; , cell <br /> ' - Cit ' ir-� .�/ ZI P: j's'Q . . <br /> Contact Person: , /�,t{C� �',,;,��}�, Applicant is: Contractor / Homeowner <br /> Emai! and/or Fax: 7�?._pg 3 _ ���� (CErcle One] <br /> PROP�RTY OWNER INFORMATIO� � <br /> Name:i D �D <br /> PF�one{day): C� 2- 3 Z- 3 f 7i � <br /> Address: [�S �qt-r•�Ara-(-� r.,'�! e.ewl ' City� (�If�iZ�'4 ZIP� .S3 q� <br /> Email and/or Fax <br /> IPROJECT INFOR ATION: <br /> Type of Project: <br /> Any earth movement may rec�uire <br /> Q Door ) MCWD review 8 ermits <br /> ❑ Remodef ❑Water Damage p <br /> I ❑Wind s) �Re air 9 Minnehaha 8202 M n e�ion{ca Blfvd��MCUVD) <br /> � P ❑St�rm Dama e <br /> ❑Sidin ❑ Resioralion Deephaven, MN 55391 <br /> �.01her:(specify) Phone: 952-471-0590 <br /> e-ra f � Fax: 952-471-0682 <br /> ❑ Fire Darr�ge 'd �� www.minnehahacreek ara <br /> Overall roje DescripEion: ,- <br /> Estima ed Cons#ruction Valuation of Project(excli�ding land) $ <br /> , � � ,.— <br /> APPLI NT ACKNOWLEDGEMENT: <br /> • grees to provide al�information required or reque:ted by the Building Deparlment; <br /> • riifies thai the information supplied is lrue and c.orrect 10�he best of hisJher knowledge. The applicant recognizes that they <br /> are solely responsible for subm�tting a complete aF�plica6on being aware that upon failure to do so, ihe staff has no altemative <br /> but fo reject�t until it is complete; <br /> • Some or all of the information that you are a�ked to proyide on this application �s classified by State law as either private or <br /> confidential. Private data is information which ge�ierally cannot be given to the public but can be given to the subject of the <br /> data. Confrdential data is information which gene rally cannot be given fo eilF�er ihe public or lhe subject of the data. Our <br /> purpose and intended use of this information is tc annually update our records and records of other govemmental agencfes <br /> _ required by law. If ou refuse ta supply the informa�ifln the a lication ma nat be issued. <br /> i <br /> Applicant's Signature: Date: `—Z�^�� <br /> Last Updated:,05-04-200� <br />