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81/Z3/2 1.8�85�53 ET T0� +952Z494616 FRUM: Z6735B9Z88 �6B1
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<br /> Gity of C�rono
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, sidin , re-roof, etc,)
<br /> i : O�`\ Mail�PO Bo�66 . , Permit number �i� 1" �:
<br /> � Q� �Crystal Bay, MN 55323-Q066 bafe received. /
<br /> �� „� ;;
<br /> �,� T" -„ s,I� Streef Address: Received by;
<br /> � 7" 1
<br /> '\�, � �% G�'� 275Q Kelley Parkway Plan review fee:
<br /> �q g� Orqnn,_L�1N 55356
<br /> \ Esxo .. _ �'
<br /> -.._f ___ _-<�� Total F�e; �CJ.J� Q�
<br /> I . Main: 952-249-460 ---�""Fax:.952-249-4616 .�hNww:ci.orono:mn.us
<br /> This application f �st-be-eompte"�ed in:full and all.required.information must be submitted.
<br /> ! Incomplete applications wiN be returned. (P/ease prinf)
<br /> j GENE L INFORMATION: .
<br /> I Job Si e Address: ,/�.,��.`? ,�rt , �_�����'f''7� .
<br /> , Will th s be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No
<br /> If ye ,a speciel event permrt is required with Police Pepa�tment and Ciry Council approva!60 days pnor to the evenf. Shuttle bus servrce will be
<br /> required unless applicant demonsfrafes suffrcient on-site perking is available. Non-permitted events will not be albwed.
<br /> CONT CTQR!APPLICANT INFORMATIpN: r �
<br /> Name: �O r� ``�t�2_4� 4 vr��i�����`5 �G r.�ss..v-�c��.'�"c.r `� ��r�r C:e'. �r�..� ;
<br /> State icense# i?JC � ?� � �,y � Expiration Date: ( �� t°,6� � � f � ;� "�..
<br /> Lead ertification Number: ' � �" "^ ' ` Ex iration Date: „��,�p���;;. E ' � ""
<br /> �� t y:��.�t�•� �!` ,�.., j P� $ � ?c.. ►�
<br /> (for ork on homes that were cpnsirucied pr/or#o 79T8 ;
<br /> Phone ' � ��-:�GSn .._��1�-�� c.�f (office) (ceu)
<br /> Mailin Address: 1�'C�at � /CFC: C , ; .f. :.`�� . CitY ;c>�� �� 'r .SZIP: S:S- - 3'-�
<br /> Conta Person: �;�t„} --, - z.J i�rzc�� . �_S Applicant is: ontractor`�/ Homeowner �ci��iBo�e� '
<br /> �mail nd/or Fax: F�� -z S �" `�'�, "� �.i i/c�l�,� , C_d.r�r') `
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<br /> ' PROP RTY OWNER,�NFORMATIO '
<br /> Name: r�. ► c.k �c����e.�-��.�-
<br /> Phone daY): _
<br /> Addre • '
<br /> ,%�,�'_�, ��X _..�'�ft-.�.c'._:f� City= �'ro.r>� ZIP: S S� �3`��
<br /> Email nd/or Fax r_,, t'�c:i r_6;,ec�v .f ;
<br /> PROJ CT 1NFORMATION:
<br /> Type o Project: Any earth movement may requi�e
<br /> MCWD review 8 parmits:
<br /> r , ❑ Door(s) ❑Remodel ❑ Fire Damage Minnehaha Creek Watershed District(MCWD)
<br /> �' ❑ Re- of,asphalt ❑Repair ❑Storm Damage 18202 Minnetonka Blvd
<br /> I ❑ Re- of, cedar ❑Restoratipn ❑Water Damage Deephaven, MN 55391
<br /> i
<br /> Phone: 952-471-0590
<br /> � ❑Re- of, ather�apeciry) Siding ❑Other: (specify) Fax: 952-471-0682
<br /> Window(s) wvwv minnehahacreek.orq -
<br /> f)vera Project Description: r��.71<��;zr ��:7tp���.<��.��..1,� ct�r�;��`: f��5 f
<br /> ��: �
<br /> i Estim ted Construction Valuation of Pro'ect(ex�#uding land $; ,,� `"' c ���
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<br /> APPLI ANT ACKNOWLEDGEM�NTi`
<br /> • , Agrees to provide all information required ar requested by the Building pepartment;
<br /> • Certifies that the information supplied is true and correct to the best of hfslher knowledge.'The applicant recognizes that they
<br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative
<br /> ibut to reject it until it is complete;
<br /> �-` • Some or all of the information that you are asked to provide on this application is ciassified by State law as either private or
<br /> � confidential. Private data is information whfch generally cannot be given to the pubUc but can be given to the subject of the
<br /> data. Confidential data is information which generally cannot be given to eifh�r fhe'pubbc or the subject of the data. Qur
<br /> �` purpose and fntended use of this information is to annually update ou�records and:records of other govemmenta! agencies
<br /> re uired b law: If ou refuse to s l th�. ation,the a li ti n ma not ba issued:
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<br /> '' ADplic Ys Signature: ' �--f.-'L i��"��.�,z,-�, .y-,-,- -�-� Date: �,. �, ,-., 2..v� '"2._.,.
<br /> / ..... .,g .
<br /> Last Upd ted: OS-09-20'I 1 � � .
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