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OCT/26/2016/WED 03; 54 PM Elder Jones Building FAX No, 952 854 4909 P. 001/001 <br /> � . <br />, <br /> � <br /> �It�/ �'� �1"OI'1 O <br /> Buiiding Permit Application for IVlaintenance I Replacement! R�model — Residential ONLY <br /> (i.e.windaws, doors, siding, re-roof, etc.—NO ST CTURAL �XPANSION) <br /> ���0 Mailing Address: � Permit number: — (� <br /> PO Box 66 �-J <br /> Crystal Bay,MN 553 oo8s Date recsfved: �f>— <br /> ,� � Strset Address: Receiv�d by: <br /> �� �� 2750 Kelley Parkway Plan review fee: <br /> tqk�s�{o��, Orono,MN 55356 <br /> Total�ee: ���� <br /> Main: 952-249-4600 Fex: 952-249-46'ts www.ci.o,�q,n .�mn•us <br /> This application form must be compleied in full and all required information must be submitted. <br /> incomplete applications wilf be returned. (Please prrnfJ <br /> GEN�RAI,INFORMATION���d � �•��UUU p(�� <br /> Job Site Address: -� 'j"j1 <br /> Will 4hic be a PqrAdo ef Herr�oa, Romodob Showcaco Homo er ekk,or piaplay Homc? ❑Yeo No <br /> !f yes,a speclal ev�nf permlt Is iequi,�ed with Po�iae Aepartment and Clty Councq app�oval8a deys privr to fhe event Shuttfe bus se�vice wi!!be <br /> requlred unless applicant demonstrates auffi�rPn��n-�%ro^p��^ry Is avallable. Non-permitted events wrll not be a/lowed. <br /> CONTRACTOR/AF �I},A,t- Hv�ne Service, Xz�c, <br /> Name: _ 2690 Cumbe�rla��d�'kwy, Ste �00 <br /> State License# _ At1a11ta, GA 30339-3913 Expiration tiate: � � r- <br /> Lead Certification N� ���� ��268257 Pl�.763/542W8826 �q Z��Expiretion bate: j r- w . <br /> (for work on home, �� <br /> Phone: (ceu) ` (office) �'yr.��,s(e p S' � <br /> Mailing Address: Cit : zlP: <br /> Contact Person: Applicant i Contractor Nomeowner �c;c�iq ona} <br /> Email and/or Fax: �V���, �,� p�t�riGS . C�YY1 <br /> PROP�R'fY OWN�R INFORMATIpN; <br /> Name: ����, ��� <br /> Phone(day): _��,I 2,��(�s� ( <br /> Address: �,��, City: ZIP: <br /> �mail and/or Fax: <br /> • � 4 <br /> pROJECT INFORMATION: Ovetal! ro ect description• 4.CPi1� <br /> Type of Project: Any eactfi movement may also requl <br /> ❑Door(s) �Remodel ❑ Ffre Damage <br /> MCWD review&permlts: <br /> I-1 Re-roof.asnhalt I'"I RPnAir I-1 Rt�rm namana Minnehaha Creek Watershed Disfrict(MCWD) <br /> i�acu muuiewi��ta o�vu <br /> [J Re-roof,aedar ❑Restoration [,�Water Damage Minnetonka,MN 55345 <br /> �Re-raof,other(specFty) ❑Siding ❑Other:(specity} Phone: 952�474-0590 <br /> Fax: 852-471-0682 <br /> �1lVindow(s)�,.r� www.minnehahacreek.ara <br /> Estimated Constructfon Valuativn of Project(excluding land) $ '� <br /> APPLICAlVT ACKNOWLEDGEMENT: <br /> • Agrees to pravfde all information required or requested by the Building Dapartmen4; <br /> • Certi�es that the information supplled is true and correct to the best of his/her knowledge. The applicant reCognlzes that they are <br /> solely responsiblc for submitting a Complete appllcatlon being aware that upon failure to do so,fhe s#aff has no altemative but to <br /> reject it until it is complete; <br /> • Some or all of the information that you are asked to provide vn this application is classlfled by State law as either privats or <br /> confidential. Private data is informatfon whieh generally Cannot be given to the public buE can be givsn to the subjeet of fhe data. <br /> Confldentfal data fs Information which generally cannot be given to either the public or the subjeet of fhe data. Our purpose and <br /> intended use of this information is to annually update our racords and records of other governmental agencies rsquired by law. If <br /> ou refuse to su I th Information the a lication ma not be issued. <br /> Applicant's Signature: ���" `-'-'""�� Date: /d d(o r�� „_, <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />