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���y �� �� ���� <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> O ' Mailing Address: d <br /> � ��� PO Box 66 Permit number: �� -. D �� <br /> Crystal Bay, MN 55323-0066 Date received: - 2 S— <br /> I , ' � Sfreet Address: Received by: 2�- <br /> `� � �; 2750 Kelley Parkway Plan review fe : <br /> ` ' Orono, MN 55356 <br /> '���'��Fsri������' Total Fee: ��. �l' �� <br /> Main: 952-249-4600 Fax: 952-249-4616 ��:���c�o;:.,r�:� ;�,�; ;;;; <br /> ___ _-____ _ __ <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: I ' / i \ <br /> Job Site Address: ,,�� �v K E��Fe t W••� Zw T�; , /l1 n S`�3� ( Jrsn a � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> /f yes, a specia/event permit is required with Po/ice Department and City Council approva/60 days prior to the event. Shutt/e bus service will be <br /> required unless applicant demonstrates sufficient on-site paricing is available_ Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �_.� c���l ��1�� ���t����y � {�u..vtt c1.;n�� � <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) � i a_ �v� - -j J 1 (office) <br /> Mailing Address: � , ;}il ���, S�.�l� City: �,,/,, �� ZIP: > > 3�� <br /> Contact Person: [��,i�� �,��('���r Applicant is: Contractor / omeowner (Circle One) <br /> Email and/or Fax: ��.�pe,- i� ��r�Y C' S�"��;� � (u.^� <br /> , , � � <br /> PROPERTY OWNER INFORMATION: / <br /> Name: flf,(��/ -1 �� �-���,Y �/n��l� ��1-��y <br /> Phone (day): `1 >�l- �j'�1- �J l 1 <br /> Address: � � 1� �^,,, S�- City: U,/•.,yz�_�� ZIP: S'S3; � <br /> Email and/or Fax: �,Q�.-,p�, i�- ��r-,� L �,,y�4,/ : � v "� <br /> PROJECT INFORMATION: Overall ro�ect descri tion: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review& permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Btvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) ❑ Siding [�j Other: (specify) Phone: 952-471-0590 <br /> Fax: 952 471-0682 <br /> ❑WindOW(S) �Sr f�.f.u^� �(tnu�x�•�� _ � <br /> Estimated Construction Valuation of Project(excluding land) $ 7 �i1 J. cv <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this inform ion is to ann Ily update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the i rmation, t a lication ma not be issued. <br /> ApplicanYs Signature: Date: � ���-`�- �f Y <br /> Owner's Signature: Date: � -2 � " �-v/y <br />