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O1/25/2017 wEo 14: G1 Fax 507 3G5 5195 A 6 E ConAtruotion Suppl f�001/002 <br /> � � <br /> ��t�/ �'� al"011� � <br /> Bullding Permlt Appllcatlan fo�Malntenance/ Replacement/Remodel—Residentlal ONLY ' <br /> i.e.windows, doors, siding, re-roof, etc. — Np STI�UCTURAL EXPANSION) � <br /> Mai11nA Addreas: Permll number, . �� -��'L` C� <br /> ��� PO Box 00 <br /> Crystal�ay,MN 6b323-008$ DBte recelv9d: � 1 <br /> � <br /> 5freef Addigb8' R9C61VBd by: K�►�' <br /> ��,, �� 2750 Kelley ParkwaY pien revlew fee: I ' f� — <br /> !,� �,�' Ornna,MN 6b36e <br /> ��'� g Totel Fee: � ���r, "�j 1 <br /> Maln: 952-249�60b Fax: flb2-249a1818 www.ci,orono.mn,us � ` / <br /> ThlB applicatlon torm muat be completed In lull and all requlred Informatlon must be eubmltted. <br /> Incomplete appllcatlona wlll be returned. (Pleese print) <br /> (3ENERAL INFORMATION: <br /> Job Site Addrese� �2�'1�7 �'rs�.���:a. .�1r.,���, .. �`J.1^o�� � . <br /> WIII thle ba a Parade of Hornes,Remodelers 8howcese Home r other Dleplay Home7 Yes No <br /> K yes,a spscle►evanf permtt]e requlr�ed wNh Pollce Depennrent end Cfly Coundl approve!BO deye prlo�ro lhe evenf. Shulfle bua san+lce w11!be <br /> roqulree urlless appNcmllf�/�latab6lea sUfAclsn}on-sNe pelhMy�s evefiabla. Nompermflted eVehla W11J/rOt 40 alloWgd � <br /> CONTRACTOR I APPLICANT INFORMATION; , <br /> Name; ' <br /> State Llcense# �xplretkon Dete: <br /> Lead CertHlo�tlon Number: � Explrallon dote: ^ <br /> (ior work on hom�s fhet wero conalrucfed prlor fo 197d <br /> Phone; (ceil) (offica) <br /> M�IOng Addrass; Cily: ZIP; <br /> Contect Person: Applicant is: Contractot I NomeoWner (a.w•ono� <br /> Emell and/or Fax: <br /> PFtOPEaI'Y OWNER 1NF0 MA714N: <br /> Neme: �/,��/�c,�n�3��'lc- , <br /> Phone(day): 5c�? Z36 �r��'zS <br /> Addresa: �� 1� � .�• �v City: � .�.c' � ZIP; O� <br /> �mefl endlor Fex: ��r ,,,� <br /> PROJECT INF4RMATION: Ovarell ro ect descr tlon: <br /> Type of Pro)eat; Any eerth movement mey eleo requlre <br /> �Door(s► ❑Remodel ❑Flra pemage MCWD revlew&permlts: ' <br /> [�Re-roof,evphalt ❑Repelr ❑Slorm Qemege Mlnneheha Creek Waterohed Dlatrlct(MCWD) <br /> 16820 Mlnneionke Blvd <br /> ❑Re-rouF,csd■r ❑Restaretlon p Water Damage Minnetonka,MN 66345 <br /> Re-roof,nthet e �a Phone: 962�71-0600 <br /> ,� ( p � ❑Sldlnq ❑Other:(apeclry) Fax: 952-471�0682 <br /> .►�--Ir---1 []Wlndow(s) �yuuw.minnehahacr�ek�aro <br /> Eetlmsted Construatlon Va{uatlon of ProJect{exaludln�land) � �� <br /> APPLICAN7"ACKMOWLEDLiEMENT: <br /> • Agreet to prav{da alf information required or requeeted by the BuIIdInO Depertmenl; <br /> � Cert111es thet the Iniormation suppUed le true and correct to th�b94t of hlalhar knowledge. The eppllcent recognlzoe thet they aro <br /> salely neeponelble br submlltlnp�complele eppllcetlon baing ewera th�t upon faflure to do eo,the eteff has no altam�tive but to <br /> reJect It untll It Is complate; ' <br /> • 6ome or a11 of the Infortnatlon ►hat you 4ro asked to provlde an lhls applloatlon Is cfaas�led by Stete law aa elther prlvale or <br /> confldentlal. Prlvete dale 14 Informatlon whlch generelly cannol be glven to the pubBc but can be glven lo the eubJect ot lhe dam. <br /> Cor�ide�Ua1 dat�!e Informet�on whlch penerally cannot ba glvsn to elther tha publlo or the subJact o1 the dmts. Our purpaae end � <br /> Intended uae of thls Inform�llon le�O annuall�updele aur rocordc and rocords oi other povemment�l aBenclea requlred hy law. If i <br /> u,refusB to u I the Inforrnelibn,ihe I�aunr,ma nat be lesued. � <br /> Appllcent's Slgnature: _ p�te: _, 'Z� ! �'1 ; i <br /> Qwnar's 6ignature: � pa�; �� ` ; <br /> La�t Updel�d:Jenuery 2018 � <br /> I <br />