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I Y .� s � W _I I _ /� • , � Cit�r c�f Q►r+�n�► l� 37( . Buil ing Permit Applica#�r�� far Maintenance / Renovatica {windows, doars, siding, re-roaf, etc.) �;;�0,�,� � MailiPO Box 66. Permit number. � /� /a� �� Crystal Bay,MN 55323-0066 Date received: d' ___�.____. �� t a,�' SfreatAddress: Received by: � � ti"'/� 2750 Kelley Parkway Plan review fee: �.��sg�Q.�� Orana,MN 55356 �"" ��_.__ Tofal Fee: _ y�� .5.(p J Main: 3�2-249-4600 Fax: 952-2d9-4616 unr:w.ci.arona.mn.us , . _._ _ . ,..___._.___ • This a�plicatian form must be completed in full and all required inforrnation must be submitted. tncompiete apptications wi16 be returned. (P/ease print) GENERAL I�iFORM�ATtON; � Jab Site Address: I 2.�. l.. � ----- -.._____ _ ._.�.�N-�� Wiil this be a Parac�e of tiames,Remodelers Sh€�wcase Home trr ather Display Home? ❑Yes Ncr If yea,a special event permit is�qu+red with Polrce i�epattment and Ci1y Cou»cil approva160 days pnor t�tire evenf. Shuttfe bus s rtrice wi!/be required pnloss apptisant demonstratos sofffci�nt on-site parking is evailable. Non-permrtted everrts wU!not be altowed. CONTRACTOR/AF�PLiGA3�IT INF(}RMATIOW: Name: �"-t4lMES Gc��.i $?YLt9G'i..�pa�! State Licertse# � . l�}b l _ __�_.�.._ Expira#ion Da#e: _� 3/ ��s Lead Certification N mber: Expiration Date: (for work on home�that were ca�d prjor ta 1378 Phone: -�-• '"'?v r� (a�ce) (ceil) � ......__.__.� _.�___.. . _ - -- ___ �.2-?�4�-�.��_—._ Mailing Address: �_�v;(L Zu e� C�ty. tP: Contact Person: Applicant is: actol- / Nomeowner (Circie Orre} Email and/or Fax: �.Z��n"�ac�,C��2'LZS7an1.�°--:��G5-_�� .� '��,_ " t Ov�-LZ�� PR�PERTY OWNEI,�INFORMATIOtd: Name: ,,,�� . ..,� �' � �tf�.�E��=._ ��1�+^�.... .�-�."C:r'�_� �r�'��'�� _�:�!� ..��1�_�._._�?�'ril�C, _ _ _ _:. Phone(day): �tSZ-915" 4gC��.____ .� Address: �{3�3 �_'3�.�'�_ti—ST.E�S��c -- City:��". l.a�?.SS.r�t�z�'�iP: Emai!andlor Fax �,t}��;y�2��;:,�,p��,yh p�J(d ,�j�n}d:�°'�� C.Ut�t _. PROJ��T INFORM4AATIQN: Type of Pro}ect: Any ear#h movement may r quire ❑Door(s) ❑ Remodel ❑Fire Damage �'�wD�eview&perm' : Minnehaha Greek Watershetl[}is ct(MGWD) ❑Re-raof,asphalt ❑ Repair �Storm Damage 1$2D2 M}nnetan'ka t3tv ❑Re-roof,cedar ❑R��toration ❑Water Damage ��Phaven,MN 55391 Phane: �52-471-0590 ❑Re-roof,o#her(spe�ify? ❑Siding ❑Other.(specify) Fax: 952-471-0682 ' ❑Window(s) v,+wlv.rninnehahacreek.o OverallProjectD�cription• �'„�'rV,�gt-��,�,nl,�y' 2[�i Estimated Constru�tion Vaivatian af Pro�ec#(exciut�ing land) $�'�,�QC??p�=- APPLICANT ACK OWLEDGEIUfENT. • Agrees ta pro icJe alf information required or requested bythe Building Department, • Certifies that he information supp{ied is true and correet to the best of histher know6edge. The appiica�t rec nizes tha#lhey �r�solely res sible for submitti«g a compiete appiic�tion being aware that upon failure to do sq the staff h no aitemative but to reject it,until it is complete; + Some or all o�the information that you are asked to provide on this application is ciassified by State law as ither private or confidentiaL rivate data is information which �enerally cannnt be given to the public but can be given to th subject of the data. Confrd ntia# data is informatian which generally cannot be given to either the public or tfie subject o the data. �ur purpose and ntended use, of this information is tn annualfy u�ciate our rec,ords�nrl recards of other gouem ental agencies re uired b la . ff refuse to i th ' fo ati the a�ptication may nai be issued. Applicant's Signatur�: _ % , .. '`-�-� ------__...._ Date: _ � ��' 'Y_..___ r ; Last Updated: 08-09-2011