Laserfiche WebLink
Aug 10 16 12;36p EDL 19524709169 p.1 <br /> f � 4 �.��y �� v�v��� r��t�-5� � e� , ou-v�o. ��i�l, US <br /> Building Perrni# Application for Maintenance/Reptacement/Remodel - Residentiaf ONLY <br /> , o?D�(v�Ov 9S� <br /> �`�, Mailrng Address: permit numb� ���Lt�s V�j 8�Q//� <br /> j� '���I � PO Box 66 <br /> � \'• Crystal Bay,MN 55323-0066 ���� Date receive� e <br /> t' � r� Reoeived by: ����} • C�� <br /> . , Street Address: f <br /> ��: �� 2750 Kelley Parkway Plan review f �uSt � I�U1�13.{ <br /> \Ft `�% Qrono,MN 55356 � <br /> ��ti r s t�_����.' � <br /> _ Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 �/ �� <br /> This applicatiort form must be completed in full and a!I required information rnust �' <br /> Incomplete applications will be returned. {Please print) <br /> GENEFiAL INFORMATION: - - � <br /> .lob Site Address: �'` (s� ��� �'�v�uc <br /> WiN this be a Parade of Homes,R�e�nadelers Sho ase Home or other Display Horne? �Yes No <br /> If yes,a specia!event permit rs required with Police Departmerrt and City Courtcrf approval 60 days prior to the event. Shuttte tws service will be <br /> requirad unless applicant demonstrales sutf'rcienl on-srte parking is avarlable. Non-permitted events w1!!not be allowecL <br /> CONTRACTOR!QPPLlCANT 1NFOR�IIATION: <br /> Name: <br /> State License# <br /> Lead Certification Number. <br /> (for wark ort homes that were constructed prior to 7978 � .� � <br /> Phone: (cell} l� � �rizj / <br /> Mailing Adtlress� <br /> Contact Persan: ApF � :a <br /> Email andlor Fax: ' <br /> PROPER'FY OWNER INFORMA710N: <br /> Name: �.W o��8� ~�iFar� <br /> Phone(day): ��� - Slr��77 � 7 <br /> Address: <br /> Email a�dlor Fax: �� �,����, q a t � � ��,� 1 � <br /> PROJECT tNFORMATION: Overall pro ect descri tion: <br /> Type of Project: <br /> ❑ Door(s) ❑RemOdel ❑Fire Damage mL.wGr rev�ew a�permr�s: <br /> Minnehaha Creek Watershed District(MCWD) <br /> � Re-roof,asphalt (�f2epair ❑Storm Damage 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑Res#oration ❑Water Damage Minnetonka,MN 55345 <br /> ❑ Re-rflof,other(specity) ❑Siding ❑Other: (specify) Phone: 952-47'f-0590 <br /> Fax: 952-471-06$2 <br /> ❑Winclow(s) <br /> Estimated Construction Valuation af Project(excludi�g land) $ • <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all iritoimacion required or requested by the Building Department; <br /> • Gertifces that the informat€on supplied is true and correct ta the best of his/her knowledge. The appficant reoognizes ihat lhey are <br /> solely responsible for submitting a complete ap�lication being aware that upon failure to do so, 1he staff has no aliernative but to <br /> reject it until it is complete; <br /> • Some or all of the inforn3ation that you are asked to provide on tl1i5 application is classifced by State law as either private or <br /> confidential. Private data is irrformafion which generally cannat be given to ihe pubtic bul can be given to the subje�t of the data. <br /> Confdential data is infarmaiion which generally cannot be given to eiEher the public or the subject of the data. Our purpose and <br /> intended use of ihis infarmation is to annually update our records artd reeords of other goverrsmental agencies required by law. If <br /> ou refuse to su f the information,the a lication m2 not be issued. <br /> App�icanYs Signature: Date: <br /> Owner's Signature: Date: <br /> �� <br /> ;v �G� -.� ��� (� <br /> � <br />