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J <br /> --{. �� � c� <br /> City r�f t�rvno <br /> Build�ng Perrnit App�lication for In#ernal Work <br /> {windows, doars, siding, re-roof, etc.) <br /> �...-- AdatlingAddrerss: Q� ��/p� <br /> ���,0,��. PQ Soz 66 Pem►if numbsr. <br /> � � Crystai Bay,MN 5�323-0066 Date received: /O -0�.3 -/ <br /> �0 +� <br /> � R�:eived by: L�3`YLC(-(.�_ <br /> � � . � �+-' s. Street Ad�iress: <br /> �i .t.= <br /> .� `�' 2750 Keiley Partcway Pian review#ee� <br /> �L9k�3tid�'� �R7R0� l�A(�1 Jr$3$s / �""� <br /> �-__-� T�,F�: , a�s�.� <br /> Main: 952-249-4600 Fax; 9�2-249-4616 vwvw.ci.s�rono.mn.us <br /> This�ppliCafion fotm musi be completed in fuli and all required information must be submitted. <br /> incomplete aµpiiCatians wifl b�returned. (Please print) <br /> GENERAL INFORMATIQN: ,/ ��� �� <br /> Job Site Address: ��. <br /> Witl this he a Parade of Hames, Remodelers S awcase Hom �oth�r Display H e? es Na <br /> 1f yes,a spaciai event permrt is requered wlth Pdice Dapartment snd City Council approva!6D days prior to 1ha euent. Shuttie bus service tvill6e <br /> requlred unfess appllcant demanstrates s�arent on-site parking 1r avaBBbte. Non-perrnitted eve�fs wiN nai be allawso` <br /> CtJNTRACTOR t APP�(CANT 4NFORt�IATIC�F1: <br /> Name: G""loF'c�Cri�t.�Vrt¢.S �;���IbY'� <br /> State License# Expiratipn Date: �.. (^ ! ^�_ <br /> Lead Certification Nurnber. � �-. Expiration Date: <br /> (for work on hames that were corrstructed prior to 19T8 <br /> Phane: (�� - - (offiee� � � - Q'�{--��Lf jceli) <br /> Mailing Addre&s: � _� _ City � �� ZIP: ��"'��— <br /> Co�tact Pers.on- Applicant is: o tra r Homeowner �cir��ao�m} <br /> Email and/or Fax: �y,,,� <br /> PROPERTY OWNER INFORMATION: / �/� <br /> Narne: ��c2 � ��'+t�✓ut�."in..rt' Y��'.�.in..� <br /> Phone(day): �� �C�"* �',�"'�' <br /> Address: ,S'�jp� W . ?.���ri' �"1": City.�t.n�.ct� �ra.r�ZIP: -,._,�'� ��k� <br /> Emaii andlor Fax ����h "��-�yti��— <br /> �Y�anrw�lo rr�nnn�.e.r-� ��� c f b•�aw. <br /> PROJ ECT INFQRMATION: <br /> Type af�roject: Any earth movem�ent sr�ay require <br /> ❑Dc�or(s) i ❑Remodel ❑Water Damage MCWD teview 8 p¢i't1�tt5: <br /> Minnehaha Creek Watershed bistricf(f+hGWD) <br /> �Window(s} � ❑Ftepair [{Storm Damage 182�2 Minnetonka B►vd <br /> � Dee h�ven, MN 5539'I <br /> ❑Siding � �Restar�tivn ❑Other:(speclty) � Ph ne: 952-47t-0590 <br /> ❑Re-roof ❑Fire Qamage Fax: 952-�471-�s82 <br /> wtivw.m fnnehahacreek.ort� <br /> C}verall Pro ect Description: y� ,� � <br /> Fatimatsd Construction Valuation af ProJect(excluding tandj � �� ���CJ�� <br /> -- - � <br /> APPLICANT ACKMOWLEDGEMENT: <br /> Agrees to provida ali infwmalion required or requested by tha Buildiny Departmen� <br /> . Certifles thai the information supplied Es true and correct to the besE of his/her knowledge. The applicant r�ecogni2es that they � <br /> are solely responsible for supmiuing a c�omplete appilcaiion being aware that upon faiture to do so,the siafi has no altematNe E <br /> but to reject it untii it is complete; � <br /> � Some or alf of the fnfortnation that you are asked ta pmvide an this applicatfon is classified by State taw as aither pnvate or � <br /> confidentiai. Private data is informatian whir,h �nerally canrtot be given to the public but can be given ta xhe sudject of#he � <br /> data. Confuiential data is infwmatlon which generai{y cannot be given to either the pubiic or the subject of xhe data. Our <br /> purgose and intended use of this ir�fprmation is to annually update aur recards and records of othe�govemrnental agencies <br /> re uired b law. If u refuse su�k ir�f nn ' n,the a lication ma not be issued. <br /> Applicant's Signature: � Date: ��' ��'�ta�� <br /> - Y <br /> Last UPdafed: 03-c�1-2011 <br />