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Sep 0216 06:16a EDL 19524709169 p.1 <br />.�n- �� Q� , �.��y ci� vrv��� r��i�so � �i , o�r�r�v. c�r�, �� <br /> Buildin Permi�Application for Maintenance/Repfacement/Remodel—Residen#ial �NLY <br /> �,/�O A,� ��P��S= Permit number: O r� 7 <br /> �VO �•., ' — <br /> ;` Crystal Bay,MN 55323-0066 Date received: <br /> � ; ,� S7reef Address: Recei�ed by: � <br /> I�`\•F.� �;��i 2750 K�ley ParkwaY Plan review fee: <br /> � Orono,MN 55356 <br /> �.�A-F_SH���t <br /> Total Fee: <br /> Main: 852-249-4600 Fax: 952-249-4616 <br /> This application fortn must be completed in full and al! required informatian musE be submitteck. <br /> Incomplebe applicat3ons w111 be returned. (Please prrnt) <br /> GENERAL INFORMATION: � ���3 j <br /> dab Site Address: � (�.� r�1 ��'1 ut ,�('21"�, � <br /> Will this be a Rarade of Hames,�e ��odebrs Sh ase Home or other Display k!o e? Yes No <br /> It yss,a special event permlt is requirod with Po6ce Deparfrnent and CIry Cow�cil approva!60 dsys pNor to the evem. ShuttJe bus service wiJ!be <br /> reqatrec!unless app!'rcant demonstratss sulf�cient on-siha parking is evaiJ�ble. Non permiKed events wlU not be al/owed. <br /> CONTRACTOR IAPPLICANT INFORMATION: ��� � �o� _���w�� <br /> Nairte: <br /> State License# Expiration Date: <br /> Lead Ce►tiFication Number: Expirafion Dabe: <br /> (for wark ar homes il�at wene constrvcteQ prlor to 7978 <br /> Phone: (cell) (office) <br /> Mailing Address: City_ ZIP: <br /> Contact Person; ,. � Applicant is: Cantractor 1 Homeowner tc�ea,e� <br /> Ernail andlor Fax: <br /> PR�PERTY OWMER INFORMATION: <br /> Name: �e�rj�v�.��r� �,� <br /> Phone(day): (�l� �Cr�.i�'77�� 7 <br /> Address: / �"''- City: � ZIP: ,�� <br /> Email andlar Fax: � ' � <br /> : � <br /> PRO,JECT INFORMATION: Overatl prdect description: 'iC. ' �iii-�" �1` • �' d F'�►-�%�ti � �S`�"���" <br /> Type of Project: Any earth movemerrt may also req�ire nurL <br /> ❑Door(s} ❑Remodel ❑F�re pamage MCWD revlew&permits: � <br /> Minnehaha Creek Watershed District(MCWD) ; <br /> ❑Re-roof,asphalt �Repair ❑Storm Damage 15320 Minnetonka Blvd �//�� <br /> ❑Re-roof,cedar ❑Resloration ❑Wffier Darnage Minnetonka,MN 55345 Ir� <br /> ❑Re-roof,ott�er(speciry) ❑Siding ❑Other:{speafy) Phone: 952-471-OS90 7' <br /> Fax: 952-471-0682 <br /> ❑Window(s) <br /> Estimated Constructiqn Valuation ot Project(excluding landy $ /,BOa aQ <br /> �_.. <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees ta provide ali infoRna#ion reqaire�or requesfed by the Bui(ding Departrnent; <br /> • Certifies that the infomiation supplied'es true and oorred to the best of his/her knowledge. The applicarrt recognizes that they are <br /> sotely respansibfe for st�bmitting a aanplete application being aware that upon failure to do sa,the staff has no altemative but to <br /> rejed it untit it is complele; <br /> • Sane or all of the infom�atior� that you are asked to provide on this application is classified by State law as either�rivabe or <br /> confidential. Private data is ir�formation which generalfy cannot be gi�en to the�blic but can be c',}nren to the subject of the data. <br /> Confidential data is infarmatiori which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> iMended use of th�s�nformafion is to annuaUy update our reoords and records of other governmental agenaes required by law. If <br /> u refuse to s I the information the a licatiom m �Qt be issued. <br /> Applicant's Signature: + L� Date: ��-/a -�� <br /> Owner's Signature: _,�� A' S� Date: O ���1�t <br />