|
`� (o -17- j
<br /> � �l�J 7�
<br /> Ci� �f Ort�:r��a
<br /> ' Buiiding Permit Appl�c�t�on for Maintenance / Ren ation
<br /> (windows, doors, siding, re=ro€�f, etc.j
<br /> � Maiflng Address: �
<br /> �,�'�,�,��� PO Box 66 �'��+i#number: —
<br /> j�/ µ �\\ Crystal Bay,ti1N 55323-0066 Dat�received: — —/
<br /> �� �
<br /> �
<br /> �� -,,. -
<br /> � ' a,��� SUeet Address: Received by:
<br /> �� ` -V �,�;,' 2750 Kelley Parkway Plan review fee:
<br /> ���ag�og��' Orona,MN 55356 �'—
<br /> �' Totaf Fee, � �7, Z�7
<br /> Main: 952-249-d800 Fax: 952-2A9-d696 vnv�n.ci.aronn.mn.us
<br /> This application farm�must be completed in full and al�reQuired infortnation must be s bmitted.
<br /> tncompl�ete applications will be rete�med. (Ploase p�lnt)
<br /> �E ERA�INFORMATfON:
<br /> Jo� �€t�Address: � '2� _. �'�,��,.l.�11' �..--'S�1C�Ls,��'`�____.__t'..����..�___3�� .___
<br /> Wit this be a Parade of Hames,Remodel�rs Showcase Home a�c�ther Dispiay Wome? Yes tda
<br /> yes,a speclal event permi:ts rsqu�red wlih Police Departrnent and CrYq Counci!apprvva!60 days prlor ta the everd. S utHe bus rvice w7t!be
<br /> requlred unless appficant demorrstjeiss su#1'rclenton-site per'dng!s avaitable, Nort-permifted avents wil!nof e alfowed.
<br /> CONSRACTQR/APPLICANT INFORMATIf}Ai:
<br /> Nartie: ��y�E� '�'�4�1�5 �+J $T►Z�G i 3�+J
<br /> State License# �, ;C�� � Ex�frati�rs C7at�_
<br /> (� .�.� � /3i/Zors-__�
<br /> Le ' Gerti�cation Number: �,9 /1'� Expiration Date:
<br /> r work on homes that were con tructed pNor to�9T8
<br /> Ph ne: off'rce cefl
<br /> �"(-�,i=��'0!—31 J�- 4 ) ' 2-- t - � E )
<br /> Ma ing Address: _�v;jL �U� City: , _ 1P:
<br /> Corhtact Person: ����y„�T �� Applicant is: racto / Hc�r� wner �c�.c�o one}
<br /> Email andtor Fax: _�f-'�,�.F'���!:,�..,�C?Rai��.,,..,.�-t4G,�'GS.C.A e�+•t t2.t�jpt�-z"�'6�Ut{___�.S
<br /> _._....�:i�_..�� �
<br /> PRpPER"CY QViINEFt tNfORMA71dN:
<br /> Na e: �-�T�-?�a�.JS �'i��►��r.1��__��...}�� z�,.__ �?'t'�t1�Gr'47K� al.�t -trJ
<br /> ne(day}: �Csz-9 t 5. ct3,�,-�-
<br /> Ad ress: �b0o___`3'�_i_2t __5'C'E�G�?._._ _._._._City:�-j. t.o�.SS__ ttr �li': �...
<br /> .. -- __. _._
<br /> Emjail and/or Fax ��} , �;' r
<br /> P OJECT INFORNIA7lON: `.
<br /> Ty�e of Project: Any ea�tt�movem nt may require
<br /> ❑ oor(s) ❑Remodel ❑Fire Darnage ����� &��m�'
<br /> Minnehaha('�-eek Wate hed Qistrict(MCWD)
<br /> [� �-roof,aspha(t ❑Repair ❑Storm Damage 18202 Minn onka Bhrd
<br /> � e-rooi,cedar 0 Restoration ❑Water Damage Deephaven, N 5539t
<br /> Ptione: 952 71-0590
<br /> ❑12e-roof,other(specNy) [�Siding �Other.(specify) F�c: 952 71-0682 °
<br /> [�VJindaw(s) unvw.xninneh� �acre k�.or
<br /> _—... a..__ ---- __ _...�.. _.�_
<br /> Ov�e�ra4t Project Descnptian._ �_,_T�_.__���__.S�!��1�._31/
<br /> �. _�_a
<br /> Es imated Construction Valtsation of Project(exc{uding fantl) $ �,y' �9��J, � 4 __
<br /> �
<br /> A LIGANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all infoms�tion required or requssted hy the Building Department;
<br /> • Ce�es thaf the information suppfied is true end ca�ect to the best ot histher knowledge. The ap icant reoognizes that tihey
<br /> are solely responsibfe for submiKing a complete appiication being aware that upon faiiure to da sa, �sfaff'h8s no altemative
<br /> bui to reject it untit it is compl�te;
<br /> • Same ar atl af fhe informatiari that you are asked ta provide on Ehis spplication is classified b}r law as either private or
<br /> ' confidentsai. Private dats is information which generally eannoE be given to the public buY can be en Eo the subject of thg
<br /> � data. Gortflderrtiat data is in€ormation which qeneralty cannof 6e given to�er ihe public or the subject oi the data. Qur
<br /> purpose and iMended use of this information is to annuai3y��adake our records end racords of ot r govemmental egenci�s �
<br /> r uired b law. If ou refuse t f th info atio ,khe a ication ma not be issued.
<br /> Ap�,licant's Signature: Date: ! � ����� �
<br /> Lasb Updated: 08-09-2011
<br />
|