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� _ � � I <br /> � City of Qrono <br /> Builc�ing Permit Appl�catian for Main#enance / Renova#ion <br /> windaws, d+oars, sidin , re-roof, etc,} <br /> Mailing Adcfi+sss: Perrrat numt�r: � � <br /> O�Q,�O , PO Box�6 <br /> Crystat Bay,MN 55323-0066 Date rec�ived: / <br /> St�et Address_ Received by: <br /> � _— _--- �7 <br /> �'.�, G�i 2T50 Keiley ParkwaY "view fee: �, <br /> �a�� Qrona,MtJ 55356 �/�,/ o�f0 <br /> -�'' ! Totai Fes: <br /> Main: 52-249-46Q0 Fax: 952-24'9-4616 w�t+w.ct;oronamn.us __/ <br /> This�pplication form must b�compteted in full and aU required information mu . <br /> Incom�iete appiications will be retumed. (Please prfnt) <br /> GENERA�INFORII�ATION: <br /> Job SFke Address� 2G��_l�."�d..�'� p�l��et��l --�l�i J Z � <br /> Witl this be a Paralde Qf Homes,Remodelers Showcase Home or oth�r Q[splay Home? [ Yes No <br /> K yss,a speclaf ev9nt permtt is reQufred wJth Po1ke Department snd Ctry Coernci►epprovai 60 dsys prior to fhe event. Shvttfe bus se 'ce will be <br /> tgquireb uniess applicent demonstretes su/flcient on-slte parkJng!s avalfable. Non permitfed events wU/nai be aflowed. <br /> CONTRACTOR/APPUGAMT INFOR�AAATIt'3N: <br /> Name: � (�pYZtlOrJ '�`�kiMi�g GO+J ST►Zt?G'T�'O� <br /> State Licensa# ' G S� �Q�j Expiration Date: <br /> Lead Ce�tifica6on 1Number. �g //�. F�cpiration Date: <br /> (far wo+lf orr hoe�I�ss tbat were con tructsd prfor to 19T8 <br /> Phone: — ll (of�'Fce) 2..:�� - � tce(I} <br /> Maiting Address: ,� � � Z-5�,�}�. 2,c�c� City: � 1P: <br /> Contact Person: � ,4ppbcant is: ctot / Homeowner tctrc�e o�e! <br /> Email and/or Fax: � � �kM r �j <br /> PROPERTY OWF}ER tNF�R[�Al'IQN: <br /> fVBttte: � � ' :�'i�T, �'c 4 N`i <br /> Phone(daY)� ' `�52-�115� ��,�- ZIP: <br /> Address: � J`�btlO 3 T City:�'('.1.4tn5 ptirt� <br /> Email andlor Fax � �A �; <br /> PROJECT tNF RM/�1�TION: <br /> TYt�e of Project: Any earth mt�vemerst may uire <br /> MCWD revlew 8 perm - <br /> ❑Door(sj ❑Remodel Q Fire Damage Minnehaha Cr'esek Watershed Dis ct(MCWD) <br /> ❑Re-roof,asphai� ❑Repair []Starrn Damage 18202 Min�etonkg Btv <br /> ❑Re-roaf,cedar i �eephaven,MN 5539 <br /> ❑Restoration ❑Waier i3amag� phone; g52-471-0594 <br /> ❑Rs-roof,othe�ifipeciiy) ❑Siding p Othar:(specify) Fax: 952-471-Ofi82 <br /> i <br /> �w.ndow(S� www.minrtehaha ek. <br /> Overail ProjeGt t�esc.ription: �SrVs,t �.JN1?' �f <br /> Estlmated Cansp�uction Valustion of Project(excluding tand) �;�,,�9 t)C O,-- <br /> APPLICANT A I KNOWi.EDGEMENT: <br /> • f�r�s to�rovide all information required or requested by tfie Building Department; <br /> • Certifies tl�at the infortnation supplied is Vu�and ccxract to tl�e be.st-of hislher knowiedge_ The ap�ic�ant nizes that they <br /> are solety'responsibie fa submit#ing a carr�lete appUcation being aware tt�t upon faiiure to do so,tha staff h no aitemative <br /> but to reje�t it until it is complete; <br /> • Some a��U of Ehe infortnatian that you a�e asked to provide on this application is classified by State law as sither private or <br /> confldenti�t, Private data is ir►formation which generaity cannot be given�the public!wt can(�given ta e sUbject a#the <br /> data. Co�errtiai data is information which genere�y cennot be given m enh�the pubitc or the subject tt� data. Our <br /> purpase nd intended use of thia in#armatton is#o annually up�date our records and►�ec�rds of other gov ental agenaes <br /> re uired� (aw. if �u r�fiuse to th ' f � the eatian ma not be issued. <br /> AppticanYs Signature� Date: ` �� j <br /> �ast�pdeced: os-oa62oa a <br />