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02/18/2615 12:54 952-935-9544 MN RUSCO AGE 02/04
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<br /> Building Pe�rtnit Applica�ian for Ma��tenance / Replacem�nt / Rena ation
<br /> (No s#ructural expansian. Only wind�ws, daa�rs,.siding, re�roof, etc.
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<br /> Mailin Address; ' ' "'�``S' �;�fr�
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<br /> � Crystal Bay, MN 55323-006G `.�A�te;rac�ived��,,:_;i�'!; .;"!'��a,=�'�;�' ;�:fi��.
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<br /> 'a',x; �''� a75U KeUey Parkway �� �:Plan::revrew'fiee::`.�;'� ��;:' ..,,,.,„�;.�!.: ';?I.'G; i:;.;;�,.:::.�
<br /> �' �~ Orono MN 55356 ;t��:, ,;i�;:i,�,;;r,�.: �r�;��,�,;���i;;� �;;,�r��,��" !:;�:
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<br /> 2-249-460� Fax: 952-249-4616 www.cl.o �1'"'��^�',��'�
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<br /> Main: 85 ,,. '� " _
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<br /> This applieation form must be completed in full and required inform�ction must be submitted.
<br /> Incomplete applicafions will b retumed. (P/ease prrntJ
<br /> GENERA�,INFORMQTION: � , ��70 � ��p /����p
<br /> Job Sike Address: .��
<br /> Wp�f thls be a Parade of Homes,Remod ers Shawcase Home or other Dis y Home? Yes No
<br /> lf yos,e gpeeia!ewn!pemrlt iS 1L�quired wlth Polfce Departmem 8nd City Counci!spprova!60 d8ys plTor to the ev�nk Sht�ftle bus se uvdl be
<br /> nsqulred uMess 8ppliCant demorrstrstes sufTider►f or1-slte pallking Is avapable. Non-pErmilted evenrs wll!naf bc allowed,
<br /> CONTRACTOR/AP LICANT fNFdfi TION:
<br /> Name: G'1�'
<br /> State L.icense� OD�! Expirativn Date: �Q3•3j.
<br /> Lead Gertification Number: � �yfQ Expiration Date: �� f�/,�
<br /> (for wnrk on homes that wars constructed pdor to 4978 /� �r
<br /> Phone: (Gell) �• '�Z '�/� (office) `7�� ��tQ� ���
<br /> Mailing Address: jy�2� City: ZIP: „�
<br /> Cnntact Pef'son� ,��� �f�J�,g _ Applicarrt is: antfacto / Hameowner �ci one�
<br /> Emai►and/or Fax: —'
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<br /> PROPERTY O1NIV�R WFO MA N: , , /� rl�,�
<br /> Name: Q � C,� ,�rc
<br /> Phone(day): � lv/2• • $ I
<br /> Address� � ��� City: �(�Q ZtP: �j �
<br /> Email and/or F�x: %/u�� ��' ��'��
<br /> PROJ�CT{N�ORMATIpN Overall ro'ect descri tion: �L[J�/�l� 5 �� �D G�A �� ;,�yt;
<br /> Typ�of Project y r�l•
<br /> Any eaeth movemerrt�na also requ ro ,
<br /> ❑Doar(s) �Remodel ❑FEre Damage M�������"�`p�"m�;
<br /> ❑Re-roof,asphak �Repair ❑Storm Damage Mlnnehaha C�ek Watershed District(M WD)
<br /> • 182a2 Minnetonka Blvd
<br /> �Ra-roof,cedar �R�storation ❑Water Damage Deephaven,MN 55391
<br /> �Fto-roof,other(speclfy) ❑Sid' ❑Other.(specify) Phone: 952�71�-0590
<br /> Fa7c 952-471-0B82
<br /> ��pw(g) www.minnehahacreek.ora
<br /> �stiirr�ated Construction Valuat;on af Project(exCluding fand) �_ � �`�`
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<br /> APPLICANT ACKNOWl.EbGEMENT:
<br /> • Agrees to provide all Information required ar requested by the Buildirfg aepartms t;
<br /> • Cerdfles that the infarmation supplfed is true and coRect to the best of hislher knowledge. The appiicant recognizes khat they are
<br /> sdlely responsble for submitting a complete appifcaUon being aware#hat upon failure i�o do so, the stafF has no attemati e but to
<br /> reject it urrtil it is complete; �
<br /> • Some or all of the informaUon that yau are asked to provide on this appi'rcation is classi�ied by Stato law as eifher p' or
<br /> oonfrdenti�l. Privat�date fs Infortnation which generally CBnndt be glven to the public but can bo given to th�swbj�d of e data.
<br /> Canfiderrtial data ts fnformati4n which generally cannot be given to either the public ar the subject of the dsta. Our pur se and
<br /> intended use of this informatlo is to ann Ily update our records and records ot other govemmentat agencies required b �aw. If
<br /> ou refusf ta su the in a�o th a i nat be issued.
<br /> ApplicanYs Sign�#ure: Date: '�
<br /> Owner's Signature: _,,, __ Date:
<br /> LBRt Updated:03/0612093
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