2016-00423 - re-roof - Laserfiche WebLink

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From:Nic Poncin Far.:(651)430-3706 To:+1952�494GI6 Fax: +1 95224946 1 6 Page 3 of 3 04l2512016 11:3'I RM � . . �t'��/ �'� ��'V il�3 Building Permlt Appllcation for eVlalntenance/Replacement/Remoeiel — Residential +�NLY �5.�". o�U��ka¢i�E7�v�, ?��:t��``'a. s::;z"19£. .''i-.-d"�?�FE", �'��;., m �� .��?u�.s�;��._, ��'� $��4,�+�'��'�P�� ` /��h T MaiJing Address: Perm�t number: � -�� l 1 V� PO Box 66 ' � Crystal Bay,MN 55323-(?066 Date receoved: � -�/� �, � Received by: Sfreet Address: �+5 � 11 2750 Kefl�y Parfcway Plan revigw f2e: �Ft,� w�' t7rono, MN 55356 ��. � '�.,�k�Sti��' � � -�,�.� Total Fee: Main: 952-249-4640 Fax: 952-249-4616 wv�tnr_cLorano.mti_us This appiication form must be completed in fuil and al!required information must be submitted. Ucorrtplete applications wil!b�returned. (Please print) GENERAL iFiFORMATION: �iok�SiteAddress: '�`�j$� �ate�� Ar�,� Lan� r ��"ono YY1N 5 Gy W6EI this be a Parade ot Homes,Remodelers Shouvcase Home or other Display Nome?�--�]Yes No !f yes,a speciaf euent permit is required with Police Oepartmerrt and City Counci!approvaf&0 days prior to the event. ShutUe bus se�vice wit!be required unless app(icant demonsfrates suHrcient orr-site parking is avarlable. Non-psrmitted events will rrof be alfowed. CONTRACTOR/APFUGANS I�dF�RMATION: IVame: ---�r a�-�'S�1'►e.� t�e�rr.P. S�rv.�Oro v'G�er��'S . .�.e C. State License# ��, �� y Expiration Date: ��ao/7 Lead Certificatian Number: �j�.T_ ��y_ �, Expiration Date: /l i��,�.o,�� (for work on homes that were constructed prior ta'1978 Phone: (cell) (office} Mailing Address: �'S' � �, � �� City� � ,�,�� ZIP: �; � Contact Person_ ma,.,��, Applicant is on rac or 1 Homeawner `c;rc�or,e� Email and/or Fax: Ynrar a`wl�?.n �,µ�-S�rv�`ce, eo rrd RROPERT"Y OWNER INFCiRMAT101V: Name: Gk..� t:ua,l-o�s�� Phone{day): �s�— H� P� c7 SSH '_' - Address: $�t5 FD�eS�- A-f�YtS l.a.�� tY� �MnO ZIP: �',5'3b� �mail aesd/or Fax: C.u.� F an $��n��I. �r rri F'Ri3JI�CT IMFORMATION: OveraU projecf descriptian: Type of P'rogeci: dny earth movement may alsa requ[r� ❑Door(S) ❑Rernodel �Fire Damage MC1ND review&permits: ph ❑Repair ❑5torm Damage Minnehaha Greek Watersfsed District MCWD j�'Re-roaf,as �ht 15320 Mi�netonka Blvd ( ? ❑Re-raof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 Phone: 952-471-0590 ❑Re-roaf,other(spe�tty) ❑Siding ❑O4her.(specify� Fax 952-471-d682 ❑Windaw(s) _—__—__� wwtiv minnehahacreek.�rg Estimated Constructlon Valuation of Froject(excludirtg lanef) $ t�, BOD. o� .— APPLICANT ACKNOWLEDGEMENT: . Agrees to provide all informa4ion required or ret}uested by the Building pepartment; • Certifies that the infortnation supplied is true and correct ta the best of hismer knowledge. The appficae�t recognizes ti�a#they are soiely responsibie far submitting a complete application being aware that upon failure tp do so,tha staff has n4 altemative but to reject i4 untii if is camptete; • Some or al1 of the information that you ara asked to provide on this application is classified by State law as either private or confidential. Private data is informaGon which generally cannot be gi�en to the public but can be given to the subject of the data. Canfidential data is information which generally cannot be given to either Ehe pubiic or the subject of the data. Our purpose and intended use of this infofmation is to annually update aur recards and records of other governmenta!agencies required by law. !f ou refuse to su I the information,the a Eication rrza not be issued. Apptieant's Signature: �G�t.� '?K,��r.,�r�c.�. Date� '`l�l.�6I/ �v Owner's Signature: Date: Lasf Updated:January 2096 ('�u.lt� �ew ��"2 2m,a�/ � � ��mr� �' /?'l�c►^,`.�C�Hi�Se�✓�r.t . Cv.s-t?