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J � <br /> 64/22/2014 12:22 9528885554 PAGE 61 <br /> ��,�.�s�, ����, ���+�� � �'� c�(�. <br /> . � � � <br /> Ci�y of C3rono <br /> Building permit App�icat�on for Maintenance / !'�eplacement / Renovativn <br /> (No structural expansian. Only windows, daors, sid;ng, r�.�roo1�, etc. <br /> �o,� MaNing Address: <br /> � Pq Box B6 ;Pertti�nwinb�r;;. -. <br /> Crystal 8ey, MN 55323-OOfi6 ` � � <br /> ��F��tA"t'er;�iW�1dt .,, .Tv�-- <br /> � StreetAddress.� 'Fi�'iv�id,Ly�'.' " <br /> y� � 275D Kelley Psrkway ;. ::,,�,,:,:..,, :,��•. : . .��, <br /> �'�$ s�p `� Oron��MN 55358 ';,�I�FY�r�evj�Yli7'�g f �,. � � <br /> Main: s52-249-46pp �ax: 952-249-4616 �T�otail��ie�; � �' <br /> 7hiS appliaatlon form m�st be cOmple#ed in futlwa I mno.mn.us ;'. '„'��,�'��' <br /> Incomplete applicatfons will be r�turned.d(Pe se print) ust be submitted. <br /> G�NERAL INFORMATfON: . <br /> Job$ite Addrass: b m � �'�' <br /> Wil!thls be a Parade of Home$, f�emodefers Showcase Wnme or other Dlsplay Home? ye$ <br /> If ys�,a speclal evenr permlf!s requf�d wifh polica bepanman�a»d Cpy Counc!!� rove160 da N� <br /> required unless applicanl derrronst�tes suHlclAnt on•slte park,ng Is avai shls. nlan-�rmi ed avar�tsVuv�p n Shb�jjo�aQN�W�ll be <br /> CONTFt�qCTOR 1 APPLICANT IN�'ORMATI�N; <br /> Name: �,IG, -- ��y�� ' � � �R Q l,L��.�t'�C� 1��`� <br /> S#ate LiCense# �� � `�"" <br /> L.ead CertifiCation IVumber. Expiration Date: ,� _ <br /> (for work on homes that werp con�$q��pnor�0 978 Expiration pate: ��n� �� ����, <br /> Phone: (cell) ) � S��f <br /> Mailing pddress: �,� 3�-��� fo�ce �� <br /> Cantact Persvn: �'�y� �Sm�r ;3 ZIP: � � <br /> �- Appfics�nt is� Contrac � / omepwner <br /> �maii andlor Fax: � tcr►�,o a,,,� <br /> PRpPERTY DwNER INFORMATION: <br /> Name� �� <br /> Phone(day): ��_{t��� <br /> Address: � �-- <br /> Email andJor Fax: City: z�p; <br /> PR4JECT INFORMATIpN: Qverali ro ect descri tion:� <br /> Type of Project: - — <br /> -�--- <br /> ❑Door(s) � �Y eartlt movement may alsa t+equlre <br /> ❑Remadel �Fire Damage 114C1n►D►svlew&permlts; <br /> �Re-roof,asphalt ❑Repalr ❑5torm bamage Minnehaha Creek Watershed blstrict(MCWD} <br /> ❑Re-roof,Cedar [�I�estdration ❑Wafer pamage �8202 Minnetonka Blvd <br /> ❑ Re-roaf,other s ct �eephaven,MN 85�g1 <br /> ( Pe �y1 ❑Siding []Other:(specify) Phone; 952-a71�d590 <br /> -- � [1 Wlndow(s) Fax: 952-471-068z <br /> Estlmated Constructidn Valuatlon of ProJect(excluding land) � �'m�nnehahacre�Jt.or� <br /> APPLICANT ACKNOWLEDGEMENT; <br /> • Agrees to provlde all Informatian required or requested by th�guiiding oepartment; <br /> • Cerbfias that the information supplled is true and correct to the best of hislher knowledge. 'rhe applfcant rscognizes that they are <br /> solely responslble for Submltting a complete applicatlon being awar�that upon(ailure fo do so,the staff has no altematlwe but to <br /> r�jeCt it until it Is complete; <br /> • Some or aU of the information that you are askad to provide on this appllCation Is claSsifred by State law a8 eithQr private or <br /> confidential. Prlv�te dQt9 is inf�ormation whiCh generally Cannot be gl�en to th�public but can ba given ta the subject oF the data_ <br /> Confidentiel data i$information which generally cannpt be g;�en to either ihe publlC or the subJeCt af the data, Qur pul'pose And <br /> ►ntended use of this Information is to annually update our records and recards af other gQvernmental agencies required by law, �t <br /> ou retuse to su I the information,the a IicaHon ma not be lssued, <br /> �lpplicanfs Signature: �� � <br /> Date: <br /> Owner's Slgnature: date: <br /> Last Updeted;o3�oarzo�s <br />