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<br /> . Cr� af arona ��,
<br /> . Bu�lding Permit Application for Mainten nce`I ��nova#ian
<br /> � (windows, door�, sidin , re-ro ,,, etc.)
<br /> MaUing Address: '�"� ' �' ,. i�G
<br /> ��,� PO Sox 66 ��,; Perrnit number: �- �� � � � `
<br /> Q Q Crys#al Bay,MN 5�323-OOSB �k+i Date received: �� �
<br /> �� �, Sfreet Address: ��4 Recelved by. , '
<br /> �, G�' 2750 Keliey ParkwaY ';'E: Plan revfevrr fee_
<br /> -��s�dg� Orona, MN 55356 �i''� �.: >
<br /> ,°,,. To#al�ee: '�;_ ` l� '"i�i
<br /> Main: 952-249-4500 Fax= 952-249�B1$ www.Ci.orono.mn.us ,� -
<br /> This appGcation form rr;ust be compl�ted in ful[and alf requireci in 'tmation must be submitted. � • ?� �
<br /> Incomplete applications wi[i be retu�ed. (P;��ase print) � 1 j�% i ,
<br /> G�N�RAL IN�ORMA1'ION: r � , _ 1 ,, F','
<br /> Job Site Address: ----- � (�v�Cj ��+(Y��c ��ri �-�.��
<br /> Will this be� P�r�de af Homes, Remodelers Showcase Home or other pis ay Home? Yes No
<br /> !i yrs,a specia/event permit is required wfth Pol)ce Departmant and Clty Cauncll a�proval BO d�ys pdor fo the evenf. Shutfle 6us senrice wil/be
<br /> requfrsad unless appllCant d�monatrxfea acJfPfcient on�ife perlcin�is eVsilable. Non;�e,n,►rrBa�v�m$W;a no�be anowed.
<br /> ���,�
<br /> CONTRACTOR/APPLICANT lNfORMA71dN: :�
<br /> Name: 1��@'r���o.\ � 'A`nc�tCSeiN '��i.
<br /> ---
<br /> State License# �,��-�oq g� ;�xpiration Date: �j��
<br /> ;.. __. __....._
<br /> Lead Certifrcation Num6er� �"�� �'�.a$� �� �xpiration Date: �j f�,r
<br /> (fnr wnrlr on homgs#/aat were canstruci�ed prlor to 9978 :' '
<br /> Phone: (o��-' �(¢C{..t1,0�qn (office) :i;; (cell)
<br /> Mailing Addre&s: l�a� CO.��, �•G•� W�S�}' C���Sevt11� ZIP: SSl��
<br /> Contact�'erson: Applicant is: � bntra / Homeowner (CfrcSe One)
<br /> �ma9i and/or Fax: ,.��, !
<br /> �,�•;
<br /> pROP�R'rY ownfER 1NFORMATION: ��!
<br /> Name: ��ob��'�' —'--- - :€'
<br /> , ��r..-
<br /> Pftone(day): "
<br /> ,f,
<br /> Address: � Ci�iar: ZIP:
<br /> �mail and/ar Fax ': �
<br /> ,�.I.
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<br /> PRQJECT !N�'ORMATION:
<br /> Type of Project: My earth mQvemant may require
<br /> '�:
<br /> � MCWD re�ew&permits:
<br /> ❑Door(s) 0 Remodel ❑Fire Damage ''''�,�haha Creek Vllate�shed qistrict(MCWD)
<br /> 0 Re-rQof,asphalt �] Repair ❑ Storrn Damage �" 18202 Minnetonka Blvd
<br /> �Re-rodf,�edar [� Restoration �Water Damsge F;, �eeph�ven, MN 55391
<br /> .� Phane: 952-471-D59�
<br /> ❑Re-�oo�, other(specify) �s�d�n� 0 Other:(specify) •;;;', F�x: 952-471-o6sz
<br /> �a� � �(� ;,"� www.minnehshacreek.arq
<br /> '�Window(s) u%� :�;,.
<br /> �;�,
<br /> Overall Projec# Description: � o'�? �,�}{ G{p�c� l�', `QJX�S � �
<br /> Estimated Ccnstruct9on Valuation of Pro ect exctudln land $ �; �
<br /> F,:
<br /> —
<br /> APPLICANT ACKNOWLEDGEMENT: �'I
<br /> �;.
<br /> . Agrees to provlde all Inform�tlon required or requested by th�Building Dep�rtrrt�nt;
<br /> . Certffles that the Informatfon supplied is true ancl correct to the best of h9s/herv�nowledge. The applicant �ecognizes that#hey
<br /> are solely resppnslble for submitting a Compfete 2ppf9C�tiort being aware that�r�on faiiure to do sa, the staff has no alfemativ�
<br /> buf#o r�ject it untii�t is complets;
<br /> ���;
<br /> • Some or a!I o��he in#orma#ion that you are asked to provide on thfs appllcati''� fs ciasslfled by Steie law as elther prfvate or
<br /> confident9al, Privgte data is ini�rmation vvhich generaliy cannot be glven tv t. pubfic but can be given to the subject of the
<br /> dafa. Confidentia! dats is infiormaUon which ganerally cannot be given ta e' er the public or the subject of tfie data. bur
<br /> purpase �nd intended us� of#his information is to annually update our recoc�$ and records of ather govemmental egencies
<br /> re uired b iaw, If ou rofuse to su I the information,the a fication ma na�'�e issued.
<br /> AAnfican#'s 5ianature: ��� ;;.''. D2te: �U���� ��
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