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h I <br /> ! Clty Of O�Q�O �'�� <br /> Building Permi# Application #ar Ma�ntenance 1 Renova��on <br /> (windows, doors, siding, re-roaf, etc. ' <br /> Mai!ingAddr�ss: PermiE number. p�� ��7 <br /> ��Q�� pQ Box 66 � <br /> Crystal Bay, MN 5�323-0066 Dats received: <br /> Fteceived by: <br /> r� � Streaf Addrass: <br /> � ' , � 2760 Kelley Par[cw8y PIBn review fee: � <br /> �° Orona, MN 55356 i�a /� <br /> �-�� Tofa1 Fee; � <br /> Main: 852-249-4600 Fex: 952-248�1616 -o{,o .mn.us <br /> Thls applicatfon form must be completed in full and aE!required Information must be submitt d. <br /> lncomplete appliCatlons wiN be retuPrted- (P/e&se prinf) <br /> GENERAL 1NFORMATION: � � ()� �a � i <br /> Jab Site Address: T1 <br /> Wlll this be a Parade of Hnmes, Rernodelers Showcase Home or ather Display Home? Yes I ❑ C�o <br /> 1f y�es,a specia!event pe�mit ia rgqulred wfth PoliCe Depa�tment and Cily Cauncif approvgf SO days prlor to the 6VanL Shuftls b�us seNkB w1B be <br /> �'equlrad unless applicant derrronstrates sUR7clent on,sFte parking Is eva!lable. NGn-pemtitted events wlll not be apo�ved- <br /> CON�'RACTO�t/APPL{CANT iNFORMATI�N: Ili <br /> Name: �1 r� \ �rc�-ers�er� I <br /> State License# '$Gl�pq� Expiration Da�e: '� �� <br /> �ead Certification Numbar: � �{'� ���$3 - Expiration Date_ I y f� <br /> {for work on homes that were cor�structedprior to 1978 (cg{I} <br /> Phone: (p�j�— �� --�(.0$$- �, (offrce} <br /> Mailirtg Address: � �, , "C" We,S}- City:�p ; � ���'' S I 3 <br /> Contact Person: Applicant is: ntract / Homeowner (ctr�ie ans� <br /> Email and/or Fax: I <br /> PROP�RTY OWNER 1NFaRMATiON: � <br /> Name� - � <br /> Phone (dey): �S,`I� ' <br /> Address: (��a_ Q Clty' �»'' <br /> Emall andlor Fax <br /> PROJECT !N�'ORMA.TfON: II <br /> Type at Project: Ar�y earth mavement ay requlre <br /> MCWD revlew E�p$rmlts: <br /> [] Door(s) ❑Remodel ❑Fine Damage Minnehaha Creek Watershed'I pistrict(MCWD) <br /> ❑ Re-roof,asphalt Q Repair ❑Storm Damage 18202 Minnetonk�Bivd <br /> Deephaven, MN 55391 <br /> ❑Re-root, cedar [�RestOrBtlon �Wafer Damage phone: 952-471-b580 <br /> r]R�roof,other(s�eclfy) ❑Sidlrsg Q Other� (spec�fy) Fax: 952-471-d}}�$2 <br /> S ���v�y,vww.minn� ahacreek.o�r <br /> ��ndow(s) '�l.a� _3 l�'�� ,,�:s+• <br /> Overali Pro'ect DescriptFon: <br /> Estime#ed Construction Valuation of Pro ect(excluding land $ y °.° ' <br /> APPLICANT ACKNOWt�DGEMENT: ' <br /> . Agrees to provide a1i lnformatit�n t�quired or requ�stvd by the Building Dapartment; !i <br /> . Gertifles that the inf�ormation supplied is true and carrect to the 8est of his/her knowledge. 7he applican�recognizes that they <br /> are solely responsible for submitting a compfete application bsing aware#hat upon tailure to do so,the s,laff has no aitarnative <br /> but fo rejsr.t It untii it is Complate; <br /> � Sdme or alt af the infarmation that you are asked to provide on this appilcation is cEassifieci by State la��+v as either private or <br /> confldential. Prlvate data Is iniortnati4n which generally cannot be g'sv�n to the publiC but can be aiveri.to the subjeCt of the <br /> data. Confidential data is infarmation which generslEy cannat be given #o either the pubiic or the subject of the data. Our <br /> purpose and intended use of this informa�on i& fo annually update our records and records of other gOvernmentai agenoles <br /> re uired b law. if u refuse to su i the Infosmatlon the a licatfon ma not be issued. <br /> Aonlicanfs Sianature: <br /> GJ��., �Qrv�.��G".� Data� �V ��"E �� <br /> �III <br />