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0^;79i�016 12 4C FAX 94? 393 37iif; R T 4,' ?NCi:RF�RATF� fQOt?1/OUt <br /> � <br /> City of (Jrono <br /> 8uitding Perrnit Appiicatlon for Mainten�nce i Replacement/ Remodel - , ' g����`. <br /> (i.e. windows, doors, �iding, re-roof, etc. - NO STRUCTURAL �XpANSIOtV) <br /> ��A,.O Mait�np Address —'�— <br /> `V PO Box 86 Per,nit n�umber, t� �4m-oC� OS <br /> Cryatai Bar, MN 55323�0066 Ueffi ta�ivGd� ,3 — ( — <br /> s� � Strset AddrB,qs� Rea�lve0 by: �Y1/1 <br /> � 2)50 Kelky Pe�kway Pla�rovbw feo: <br /> �1,��sy���t Orano.MN 55356 <br /> Mam: 952•2a6-4g00 Fax� �52-248-4818 Total Fe9: � 3 C�l � <br /> __ ._ �t.Sl�E�i�4!?1::.laII J <br /> ThlB BpplicaUon fOrtn must be completed in fuil and all requUed informaHon must be submitied. <br /> Incomplet8 appilcatlone wiil ba►gtumeC. (Please pnnU <br /> GENERAL INFORMATION: <br /> Jab SItB AddrV88� ��� ��a�fa�n. � `: �v �}�' . <br /> Wili thls be a Par�d+�ot Nomes,R�mode{ers Showcade Home or otho�Dlaptsy Home? Yas o <br /> HY�+.�aGeClei rvrnt p��iy�u'�eC wlth 1�jti�pepe�tr,»nt end Crty Councr approvd 6p deyi pnor b fhe eYertt. Shutlh(wi wW pa <br /> R�q��O UM08s ftpyl�CMt a�vmmcnafrg!6a auRiclsn!c✓+-f/f6 pBrkrn�i5 evB��eWe M1bn�DMttRted tvertA4 wafl ncY br Niowyd. <br /> CONTR/tCTOR/APPUCANT INFORMATION: <br /> Name: �� <br /> � � <br /> �.c�. ,� �- � y,<.�..r��,.k:a,'•.__ <br /> State Ucense# �, .��� � - a � - Expiration Oate• �, 3 <br /> tead Cert�IC2tion Number: ,- �, � -�.�f 2�'��' <br /> _�=.q � ' ���_ ExpiraUon Date: ,c �����c��-6 <br /> (I�or wwk on homes ftspt wdrm constr�rctsd prfor ro 1478 <br /> Phono: (cel!) (officel_ �j�� - 3�� - 55� �� <br /> Mailing Address' ta � ,� ,� . c� _ Ci�y: �, ZIP: �S��C, � <br /> COntBGt Person -_--- <br /> AppilCant is: ConC�BCtor Homeowner �cw.c„y <br /> Emai!anqlor Fax: -�,�,.��,�d� � rorl� <br /> �<. a��- <br /> FROPERTY OWNER IMFORMA710N: .. <br /> Name: i.�aK�,. Sav.--F�t -1- -�}N ( rptz=�sr� 'f�.:�..,.. <br /> Phone(dey): <br /> Addreaa: �'����lr,t �e '�/`<- ` i I CIty: �,��L�vt-<— ZIP: 5"535rz <br /> Emall and/or Fax: „ <br /> PROJECT lNFORMATI�N: Overall ro'ect aescri tion. r;�;r .v,. ��,eG e i, <br /> �°°t PrO�°C�' Any earth movom�rtt may N�o reQuira <br /> ❑Door{a) �'Rdmodei ❑F�ro Uamega MCWD rvvlew 6 pennita: <br /> ❑Re root,asphatt ❑Rapalr ❑Siarm Dameae Minreheha Creek Watershed DIaViCt(MCWD) <br /> ❑Re-rvof,codar R 15320 Minnetvnka 81vd <br /> � eatoration ❑W�t�r Damege Minniatonka,MN 553�5 <br /> ❑tie�roof.atha�(rp.clh! �S,d�ng ❑Otha��.(sDeafy} Phone: 952-471-0500 <br /> ❑Window{a) Fax: 952-171-068Z <br /> www minne�ah�cs�qek orv <br /> EsUmated Construcilan Valuatlon oi Project(oxciud�ng land} s���-, �, r�;�-�; <br /> APPLICANT ACKNOWLEDOEMENT: j <br /> • Agroea to provide oll InFpmiation req�ire�i pr rPquested Dy the 9u�ltli�fl DepoNnent; <br /> • Cnrtifies thot t��informatlon suppl,aci la tNe end coRect to the besl oi ni�lher knowledge 71ie appucant reaogn¢es that they are <br /> 4olely re6ponc{ble for submRtln9 8 comp�ete applicatio+�being aware tnet upon failurt to do s0,the stalf hes tw aitematiw but to <br /> teject it untN tt is COrnplote; <br /> • Some or a8 of the informetlo� t�at you are aaked to provide on t1��b appliCBtion ia ciasaltled by SiAte lew aa eit�er privabf o� <br /> con6den8al. Pnvate data le InformaUon which generalir Gannot be given lo tna pub�lc but can be g�ven to!he eubJect ot the deta <br /> Con6dentisl data�a mlortnotlon wfii�qeneraliy cannot bs g�ven to either the� public or the�utrjeCi ol tne tl0m. Our purpose end <br /> intendDd uie of thi�intotrration is to ann iry uptlate our rt��yroe entl recarda of olhar govemmental ayende�requirnd by Iaw. �f <br /> .. OU I�BfU6C tb Au i �ip(R�Ofit19ti0 B i�OpD4n mfl not b9 I6aued. <br /> Appii�ant's 5ignature' �`'" � � "`��--'" _�� pet&: �C� � 11+�� <br /> Ovmerv Slgnewro. '� � � �� �- <br /> Date � <br /> uet Upd�rtr+d:Jenwry 1016 • " <br /> �� " �/� ��� <br /> __ <br />