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<br /> Building Permi# Applic�tion fs�r l�aint�nance f �eplacement ! Remcadet
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<br /> ,� "'� '�s �,ryS'.ar Bay, MN 55323-0�5 Date�eceived �'�
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<br /> � �,,� 1 Sfr€ret,�e`ctr�.s_F; � Rec,P,ved by.
<br /> '� t ' � 278�KQ�iay F�arkway ' Pisn review`ee� .__. �______;
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<br /> �� ,, Orprtc Mld 5�356 � - -.. -----}
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<br /> �J9� 9SI'2'"�APQ{� Fc�X 9�2 24`a�+.r`f6 \^,4 ,a r_tl d3
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<br /> "T�h, appl�catian f�rrrr must be complefed in ful�ar�d aEi requared intormalion rt�ust be submitted.
<br /> lncomptete app#i�ations wiii be returned. �`P(eas��r�nt)
<br /> GENERAL INFQRMATIC?N: /
<br /> .fok�Site Address: ,� �� ..'Yf-� .�, (�-f �--'
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<br /> Wiil this k�e a Parade of Nomes, Remodelers awease H e or c�ther Display Hotne? �j Yes - -f �
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<br /> 11 Ye� � , `:;a'�ven?�er*!tif rs requ r�:,�r,'r�olice Dcpartr,r�rtt and City Go�en�;;.approu�f trli day�p;i�r��ttre ever,c Shu:t±e bus servEce wi�f pe
<br /> �•�qtri!��U�lBSS ap�r�C.Bn!den!�rrstr�ta�Su�+el9n!on-stte parScing is�v8_rf8bfa A}an-,�ernta+;ed eve�tCs wv�Y nod be afiotived_
<br /> C9NT�tACTC3R 1 AF'P�.IGRNT INFC}RMATION: L
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<br /> StatE L�cer,se# �.- � t�7� fs� Expiration Date:
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<br /> �eaq G�r�ific�t,o , PJumber _ _ . ---_ __ —._�__ Exp�ration Date _ r �,.-'
<br /> � .C�:�--�_..��?�-� ��_� � ____���-��� _
<br /> {€or wark on homes fhai were constructed prior fo 4978 �
<br /> F'hone ��eii�-�� �.�:� �`�'# "� {offic�3�. �,��—� �� .�-t�S��'
<br /> (t���(iny,�tidres5 _. _
<br /> �t�_I..,�..�`� � �___.�.____..__ C rty�.. r�'�Z!P: .,sr5``�S_.�-�
<br /> �'o��t�c.f Pers�n� Ap�pi�canf is Cort��etor ! He�meowner �c��cieon����
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<br /> Er,iai!anc1,'�ar Fa;a r„''
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<br /> PROPERTY OWNER INFCJRMA7tf�lV..
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<br /> Address ��„� City: Z!P
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<br /> Emai!andtc�r Fax�
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<br /> PROJECT lNFQRMATIOF�; C?verali ro ect d�scr tion: �,��� � /� � �� ���`L.'
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<br /> � Type o#Praject� � Any earth movement m y al�o r�quire
<br /> � D�c;r;,s'- � Remodel �J Fire Dama�e �GWD review 8 p�rmits: �
<br /> ' � Minr�e�:aha reek��Jatershed�ishtcC Iv1CVFlp}
<br /> � , F����o�, asphalt �Repair ❑Storr,n p�m�qa ' ( �
<br /> ' 182J2 Minnetcnka BPvd ,
<br /> t �i F�e-rao` cedar ❑Restoratioa �1Nate�Damage �� C}eephaven MN 55391 I
<br /> F fY �' g n Other 's Pci �� Phon� 9�2-�i71-�S90 �
<br /> (�1��-r�G, other{speoi } �;idir � A� fY; �ax. 952-47?-�62
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<br /> � IE'C�JVJ 5 � �,�fPr�L �.7�1 1.� �3h�'9C'r�G'x �i:
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<br /> Estimated Construction Valuatian pf Project(exclud9rsg IancR) � �����
<br /> APPLiCANT ACKNOWLEDGENlENT:
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<br /> • Agrees to p�ovide ai!in#nrmatinn re•�;,ifeu or�equesieC by�!he Bu���fi .g Depar?ment,
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<br /> • Gertifies Ehat tt»infom�atlon sup�3ied is irue and r_orreci tc#he best.oF hislher knew,edge The applseant reCagmzes tha:?�ey are i
<br /> sUlely respons�bie for subrniiting a co=�p;ete app��cak��n aeing aware that upon fa�lure to do so, the stafif has no altemative but to !
<br /> re;eci�t unti!�t is compfete:
<br /> + Sorr� ^� ai! of the mfonnat€on ihai yau are asked ta provide on this app:icaxion is classified by State iau� as eiti�Br �rivate'�or �
<br /> �.c�nfideniial �r!vate data is information wh�ct�gener�Ily car�noi be given ta th� p�biic but ca=�b2 gtrsn to the sub}ec,ot the�ata
<br /> C;onficient�a!data €s inforrnauon w�rch generaily car,not�ae g�ven to�ither+F�e public or the subiect�f the da+a Our purpose a�d �
<br /> ��ie;aded �35�p#this infarrnaEiQn fs to annually updafe our records and reeards�f otn�r c�ovemn�ent�k agencies requirad t�y iaw. If
<br /> vcu refusP to sup��y the rnfor'matian, the applica'ion r*�. , ay not be issued J
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<br /> AoPE�cant's S�ynature � _ ____. Data � �� ___...._. _.
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<br /> '.�WRr?r'S �IQ't3tl:fC', _ Q2t�.
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<br /> £�iL09T8ZT9# �u
<br /> OHd �utssn.z� �Swy : �02�3 9T9�6�ZZ�6T �O,L W`d 90 �60 STOZ/£T/50 £ 30 � �e�"�d
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