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� � � �� i <br /> . ,_,�-►v , <br /> i of � ono <br /> G Or <br /> �'Y <br /> � <br /> �u1lding Permit Appllcatlon for internal Work i <br /> {windows, doors, sidi , re-roof, etc. <br /> �g addbss: p.m+�rnu„lpr: .�.,b/ -Ol7U � <br /> O�„O�.O Po aox ss <br /> c�ys�ei sey.Nw�-oass o���wd: � - —/� <br /> , Recei„sd by. <br /> � �� i S'deetAaAdneaa: <br /> Z75o K�lay P�ricrwy wan�vvisw fvs: <br /> OrIor10.AINd 55558 <br /> _= r�F� /5 3 . I � <br /> Mahx 249-46Q0 Fex: 952-248�616 0 <br /> Tt�s app�ion form must be completed in hdl er►d all roqulred infam�tlon,must be submittad. <br /> Inraofr+plate�tppllcirtions wlll be Mumsd. (Ple�ase prri�t) 1.. <br /> GENERAL INFORMATION: � ���� <br /> Job�Add�ass: <br /> W�tl�is pe a Pare�af anes.R�wdel.ers r r DispL�y H ? e4• No <br /> Nra,e sper.Nl eu�wM psrtNt k roqrdrocf wfh Poll�Dspei6nsK and C�r CorMcN aPProrol'60 d�s Pr�or to Ehe e�+ant. SlWd�e bue nn�,�w�be <br /> ns9+�nd�6 eppYa�nt d�rnon�nrs s�llP�rM on-mke psr/cingls av�iilabk. Niomportn�6ed�venl�w�t nof Se <br /> CONTRACTOR/IIRPUCANT INFORMATION_ I <br /> Name: o�e� <br /> State Lfcense�! Expiratio►i Qake: .. 'Z,,, <br /> Lead Certificabon NNmber: � �- Expiretlon Date: <br /> (/or woNir en Awn1�a th,,t wwe consrroc�sarpda►!o�a7a A� <br /> Phone: 3 � l`^'�"", , • �P � �. � �ri��� <br /> MeNing AddtasS: . , Cily ,� 21P: <br /> Contsct Person: Applicant is: Hom� �cacl.an.l <br /> Emeil endlor Fax: • . „ � � <br /> PROPER7Y OWN�R INFGRMATION: _ �_ _ <br /> Name- � �e ewT� <br /> Phane(dey): . � <br /> Address: u.� . '�''' �~ city. zlP:l �tb <br /> Ema�andla�Fax � � ► r�+� • �n <br /> -PROJECT INF RIIAATION: _ <br /> Typ�o�P�v�ect: � My�eaRt►move�r�eet Y require <br /> MCWD�+6visw 8 ps <br /> p oo�►(s� ❑Remoaoi t�wace�o�ama� uanne�+ana creek wacer.�hea istncc(Mcwo3 . <br /> ❑Wlnda�(s) ❑Repair ❑3brm Damagd 18202 Mmnetonke Blvd <br /> �]Sidng ❑Ra�toradon ❑Ofher.(speclly) ��P�^.MN '91 <br /> Phone: D5�2-471 590 <br /> a Re-noa� ❑Fire aemega Fex: 95z�7� ez <br /> � .ml ha ek. <br /> Ovvrall P ct�1oseAptlonp � <br /> Erti�n�d C ct�on Valuat�on of Pro e�acMi n�lan� i a <br /> APPI.ICANT KNOWLEDaEMENT: <br /> ; �� P��ell in(ormadon requirsd or requested hy fhe BuildinQ DsDeRmer� <br /> � Cerqfk�a 't tl�e ihiormeHo�auPPGed is true snd correct w Ihe best oF Fi�elher kriowledge. 7he appGca neaopniaes thal they <br /> ate raspor�sible tar submlGlnQ.a appNc2it�on bek�g aw8t�that upon tailure to do so,tfia has ro altemative <br /> but b R uMll It Is camplete: <br /> ! Soir+e�'all of tha fnlhrmsUon.that eoloed to provlde on thls apniksticn Is dessleed by Slate as e�her private or <br /> aor�iden�ial. Pdvete dete IB Nltorma n whiah peneraNy�annot be piv�en t�the DubNC but�a�•bs glve to!he subjed of ihe <br /> ; : d8ta. CpnfldeMlal ' which ge�nerglly c�rrwt !�e•giv�en to either tho p�lfc or ths su joct of tha dafa. Our <br /> purpose;ene �n ed use of this �m�aiio Is to annuaNy updste our ramndo end'r000rds of othet� ovemmental apencies <br /> ,''''' uired� rofuse to tf i w�mation the e iCeion ma not be lasued'. <br /> Aapncenc�s signacure: nate: � ° <br /> C Laet Update4: a3-¢1-2011 <br /> :_ � , I <br /> . � <br /> � � i � <br />