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ic�� 5 �
<br /> Git� �rf C3rc�r�a
<br /> Buiidin� Perr�it App►Iicati�n far lnternal �lita�rk
<br /> (windows, doars, siding, re-roof, e#c.}
<br /> �-�—-_ tNaiting Address_
<br /> ��,,,a,�� Po gox 6B f}ermit number_ �Il� -�/�T
<br /> tl \\� Crysta{Bay,MN 5�323-(}O66 Date reoeived: /�O -��
<br /> 1
<br /> ; , 1� Received by: �i�L6GL-�
<br /> �� � � �;� �r! S#reef Address:
<br /> �
<br /> ��� 2750 ltelley Parkway � Plan review#e �
<br /> �4�-,�0�� arono,MN 55356 �� / __ _
<br /> ,-��F�: �a7.3 S
<br /> -- Ma►n: 952-2a8.46t}0 Fsx: g52-249-4616 www.c�.carono.mn.us /
<br /> This appticatian form must be compteted in fuU and aiI required information must be subrnitted.
<br /> ittcamplete applications will be retur»ed. (P/ease prrnt)
<br /> GENERAL iNFaRMATIptJ: (i ,,� ,, �, ,
<br /> Job Site Address: �,�_�_�Y1� �.l11,f`t�1?^',t� �S�Ot'12�. u��� 9�.� ��
<br /> Wiii this be a Parade ot Homes, Remodelsrs Sf�qwcase Hama�[o�dter Display Ho r e— es � No
<br /> !f yRes,a special event parmit is rrequrred wfth Police Depaitmenl and Gty Counci�approva!&0 days prlar to ths event. Shu#1e bus serviee wi11 be
<br /> rer�ubed unless appllcanf demonstretes suff'rcie�t on-site parking is avaltaWe. Non-permitt�d everrfs wwritlt!nat be alkr✓rad.
<br /> CONTRACTflR/APPI.tCANT lN�FO^RMATI�N: .�t._
<br /> Name: �'1at`�,CiT',..�c.�Yt.E.S �+���1�'Gt.,C..t tbY`o,
<br /> State�ic�nse# Expiration Date:
<br /> Lead C�rtification Numbsr. � �. Ezpiration Date: �r � � E �
<br /> (for work an hames ttia t wera consLvct�ed Arfor to 7978 ._
<br /> Phane: (�'�, . (oEfu�} j'� ., Q`�`� "��.t� tceli)
<br /> Mailing Addrsss: City �,;,,t 29P:
<br /> Cantact Person: Applican#is: n trac, r Horneawner �ci.�o�}
<br /> Emait andtor Fax: y�_ C�
<br /> PROPE�2TY dWNER INFQRMATtpM: / -/�
<br /> {Vame: � �'� �1t'�-__� � ri��K�[t�� Y�'.�.,r�.� .__—_
<br /> Phone(day}: -�,. �
<br /> Address: �-�C'j,� �"-�• ?,ry�b't'~ K-�.^ City+�-��5-�.l1,C`#� ZIP: ,� t(�,�,
<br /> Email andlar Fax �#.,.�� "i���,,,h+��.�-- , �j'�, t� r�y���f--� ��� G I b•C�[1vr-+
<br /> PRQJECT INFORMA71t�N:
<br /> Type of ProJect: � Any earth movement may cequire
<br /> AACWD review 8 permits:
<br /> ❑Doar(s) ❑12emode► ❑Water Damag� Minnehaha Gevk Watershed Distnct(MCWD)
<br /> �Window(s) ❑Repair ❑Storm Darnage 182Q2 Minnetonka Bivd
<br /> ❑Siding ❑Rastorati�n ❑Other:(speCkfy) aeephaven,Mh1 �5391
<br /> Phdne: 9b2-47t-0596
<br /> ❑Re-raof ❑Fire Darnage Fax: 952�71-0682
<br /> � www.minnehahacreek.orp
<br /> (7verali Project Descriptian_ ,,�S�t a�.. �/ _ -
<br /> f C-�-{�___ _____.�
<br /> Estimated Construction Valuation af Project(exeluding tanc!} �i (�}{)� �---
<br /> APPLIGANT ACfCMOWLEDGEMEFIT.
<br /> ---__.__._.........
<br /> Agreas to pruvide ail information rsquired or reques#ed by the Buikfing Qepartmen�
<br /> � Certifies that the information supplied €S tnte attd corrsct to the#est Pf histhet knvwiedge. The appiicant r�cognizes that they
<br /> are soleiy r�spcx�ibie tor submitting a comptete appilcatfan betng aware that upon faiiure to da so,fhe staff has r►o aiternative
<br /> but tn reject k until it is complafe;
<br /> � Some or af{ of the infortnatbn that yau are asked ta provKie on this appi'ica6an is classified 6y State law as either privat� or
<br /> canfidential. Private deta is information which gstiera!!y cannot be given to the pubiic buf can kae given to the subjecf of the
<br /> data. Confldential data is infwmatlon which generaliy cannot be given ta either ttre putriic or tfie su6ject oE the data. Our
<br /> purpase and intended use of ihis infarmatan is to annualty upcsate aur recards and r2cords oi othe�govemmental agenc,iss
<br /> re uired b law. ff u refuse sup� the i orm�ti the a Ucation ma not be issued.
<br /> J . Up _�_—�L ------ ___ --
<br /> Applicant's Signatu�e: '`^ "'�-...-.---- Date: t�,�' ��` �1� _
<br /> Last Upd'died: 03-0i-201 S
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