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� r ! V�■� I�I <br /> � ���y af O <br /> ' Building Permit Appticati;on for Maintena�ce 1 Renovatian <br /> (�nrindovws, doors, sidin , re�raof, et�.) <br /> NfallingAddresa: p�mslt num r: •��. /7�CCfJ/ <br /> �a� PO�ox fi6 ' � --1 --�� <br /> Crystal Bay,MN 55323-0086 �����iy��' , <br /> o , a ; ,� ��o <br /> Rgcelved by_I. <br /> � Street A'ddress: <br /> � 2750 KeNey P�rkway .pian review�ee: -�- <br /> r� ���' Orono,MN 55356 ���� ; <br /> 'fot�l Fee_ t - <br /> Main: 952-249�600 �a�c: 952-249�616 wvdv�.ci.arono,pL�_us , . �, - �`� <br /> e t�m leted in fuil and all required information mus�be submitted. , =:��(� � <br /> T h i s a p p l�c a t i o n f o r m m u s t b p � <br /> tncomple�e applicatlbns w�ll be r�turned. (P lease prin f) �_ <br /> GENERAL 1NFORMATION: 11� �f � 1 • <br /> Job Site Address: r <br /> la Home7 Y�s No <br /> Wi11 this be a Parade of Homes, Remodelefs Shovu,case Mome or other Disp y � <br /> !f yes,&special evenf permif is IBqulnsd with 1'olke Department and CPty Councii a�proval BQ days prldr to the e nL ShUttle bcrs se�vlCe+ndl1 be <br /> rgqulred unl9&s apFlicarrf damonstrate�Sui�7cisnt onslte parking ls avaifab/e. Non-permftted eV6nts�will not be allow6d. <br /> � I <br /> CONTRAC�'QR!APPLICANT IN�ORMATION: ' <br /> Name: t�+n�cr.\ �A � tr5e.� <br /> State License#� �yG\3d9 � Expiration Da�e: 'S/3 <br /> Lead Ce�tification Number� j� — q"j �`$�I-� Expiration Dai: �( <br /> (fiar wark on homes that were const�cted prFor to 1978 0��� (Cellj <br /> Phone: ��J�-- �� -� �` re � ) I <br /> Mailfng Address: l� C. . '•CI,. W� ' CitY='t�rY�e.0�11� Z1P: SS Il <br /> Contact Person: Applicant is: ontCa or ! Nomeowner (c�rese o�a� <br /> Email andlor�ax: <br /> PRaPERTI(OWNER INF r MATIC3N�v <br /> Nam�: b �nn <br /> Phone (day): � ��Z ' I <br /> Address: � <br /> City_ � ZIP: <br /> Email and/or�ax ' � <br /> I <br /> PROJECT IN�ORMATION: � <br /> Type of Project: Any��Rh �no�ement may r�qaire <br /> MCWCj reriiew�p�rmits: <br /> Q pQpr�S� r]Remodel [�Flre Damage (ylinneheha Cre�k Watershed District(MCWD) <br /> 1$202 Minnetonka Blvd <br /> Q Fie-roofi,asphalt � Repair �]Stnrm DBmege p���haven,MN 56399 <br /> �Re�ropf,cedar 0 Resforatidn � �Water Damage p(�pne: 952-471-0580 <br /> F8X' 952-471-0682 <br /> ❑Re-roof,4ther(speclfy? ❑Sidfng ❑Qther: (speCity) ���ne �acreek.o <br /> �Window(s) <br /> Overall Project Descrlptian: f.p� � � . G ' , <br /> Estimated Construction Valu�tidn of�r je (�xcludin�land) $ <br /> 4 ^ � <br /> AP�LfCAN7 AGKNOWLEDGEMENT:' ����-� <br /> . Agrees to provids all Information required ar requested by the Suflding Department; <br /> . Certi�es that the in{�ormation supplled is ttue and correct to the best of his/her knowledge. The appliCant recognlzes that they , <br /> are soEsly responsible for submitting a complete appl[cation baing aware thai upon fialfure to do so, the sta�f has no altemative <br /> but to rajec#I�untik ii is complete; <br /> . Some or a1) of the informa'tion that you 8re asked to provide on this app���tion is classified by State iaw as e+ther private or <br /> confidential. Private data is lnformation which generaEly cannot be given to th� public but oan be given to the subject of the <br /> data. Confidentlal data is Information which gengrafly cannot be gf�en to aiiher the pubfle or th� g�blect of the data. Our <br /> purpose and intended usa of thfs informatlon is to annually updete our records and records of oth�r �ovem�ental agenples <br /> re uired b law. lf ou refuse to su I the informati�n,#he a lication ma not be lssued. ' � �� <br /> AQollcant's Sianafure: � Date: a� ��'� <br />