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� �� � <br /> � City of �rono <br /> � <br /> Buildi �g Rermit Application for Mainten��nce I �enovation <br /> � <br /> � (windows, doars� siding, re-roof, etc,) <br /> Mailing Addr�ss: Peimit number. .. D/ -�$�' <br /> O�p j,�,� �a�x ss " " <br /> Crystel Bay,MN 55323-0086 Dste.rec�ived: <br /> Fieceived by: <br /> a, <br /> Street Add�sss_ <br /> 2750 Ketley Parkway Plan review fee: <br /> � ��� drono, MN 5535fi /5� 7�j <br /> 7ata1 Fee: 7 <br /> Main: 85 249-46Q0 Fax: 962-249-4815 .c1.or no.mn <br /> Thls ap iCstian form must be campleted in full and all required inf�rmation must be submitted. <br /> incomplet�applications will be returrted. (Please print) <br /> GENERAL INFdR ION: � I O �6 `` � �r- '��� <br /> JoB Slte Address: � <br /> YYill thls be a Pared of Womes,Remadelers ShoM►casc Home or other Dtsplay Home? ❑Yes No <br /> !/yes,e specie!event rmrt is repN►+ed wwlth Polir�DePartment end Clly Couna!approva!SO days Wiorfo the evenk Shutde bus�wlll be <br /> required u less aPPricsrrt dsmonstrates sufl9clent on�slte pa►ldng is aveNaWe. �lOn pemiltted events will no#be adoWed• <br /> CON�'RACtOR 1 AP LICANT IN�ORMAI'ION: <br /> Name: � 'A '�'��� <br /> State License# G\309$ F,�cpiration Date: �J 3 <br /> �ead Certification Nucnber: �j �r � a S3 — Expiration Date: 4 <br /> (for work on l�ome f�at we►o9 constrvcied AIiOr�0 1978, (Offic8) (cell) <br /> phone: (aS1— aZ ���0$$` <br /> Malling Address: � � . � " •. We. CitY:'�,c ; � ZIP: $S 1 �� <br /> Contact Pe�son: � Applicant':s: ntra ar / Homeowner �c��.o�l <br /> Email and/or Fax: <br /> PROPERTY OWNER lNFORMATION: <br /> Name: � t� � `�Y`nl�.Y1 <br /> Phos�e(daY): � ZIP: <br /> Address: 1 C�' <br /> Email and/or Fax <br /> PRdJ�C7 tNFb ATIQN: �y��move�ne�may require <br /> T�Ipe of Pro)ect: MCWD roview S permlts: <br /> �pp��s� [�Remodel �F�e���9s Minnehaha Creek Wstershed District(MCWD) <br /> 18202 Mlnnetonka Sbd <br /> ❑�te-roof,�aphalt 0 Repa9r ❑Storm Damage p�p��n,MN 55391 <br /> [�j Re•roof,cedar I�Restoratlan ❑Water Damage Phane: 952-471-0590 <br /> R�roof,other(�s ify) ❑Siding I��er:(spec�Yy) �ax: 952-471-08$2 <br /> Q www mi ne��kors� <br /> oW�s� — <br /> Ovarall Pro'ect I?e�crlp#ion: p� 1 D�. " o �Uc� � -�21X �S C� ; <br /> Es�imated Con ion Valugtlan of Prol�ct(excluding(and) S 4( .Q <br /> APPLICANT AC OWLEDGEMENT: <br /> • Agr�es to p e$�l inform8flon�qutred or rec�uested by the Building Department; <br /> . Certfies that he i�ormatian supplied is We and oorreCt to the best aF hisTher know4edge. The applicant reoogni�es that they <br /> aCe solely r pOnsible for submttting a complete applica�on being awa*e that upon falure td do so,1he staff has no attemative <br /> but to reject� untll ft is complete; . <br /> . Spms or all f the Information that you sre asked to provide on ih�aPPlicaflon is Classified by State 1aw ss�ither pnUate or <br /> cpnf[deqti8l. Ptivate d�ta is iritolmation which generally cannot be given to the pubfio 6uE can be given to the subject oi the <br /> data. Gonfl entlal data is information whkh generally cannot be g�ven to efther the publlc or the subject of the data. Our <br /> purpose an int�ended use of this inform&tion is to annually update our records and records of other govemmanta! agenci�s <br /> uired p I w, )f u refuse to su ihe informatlon,tf'�e a lication me not be issued. <br /> AoaficanYs Sianatu e: <br /> �, o�r�: � �� �y . <br /> � <br />