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To: Page�2 of 3 2015-10-01 13:55:38(GM� 16514004483 From: Revamp Remodeling&Design
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<br /> B�ildir�g Fermit Application for 11�1�inter��r��e / Re�lacer�ent / Remo�le!
<br /> ;y_ J" .0"b'"'#" "i. y rn.�W��6."s. R b' fC
<br /> ��.:�� ����`r�.����'��=�.. ����°�, ���33"�R�, ��m��'���" �=?�u�.�„ •_ �^���..� �� ���.,,���� . :,,�.a�»� �";��,��v�.��;:����
<br /> ,: ��� '� Ntai(ing Acidress: Permit num�er: �. -(�{ �`T
<br /> � ``..� �'C7 Box E�6 � � _ _..._
<br /> ��'�� � � � �ryst�l B<�y,MN 55323-0066 � Datie receivect: f a-" `"��
<br /> j � 1'I � R�eived by. I
<br /> ; ��P Street Address�
<br /> � �' �. ;
<br /> ',.y ,� ;� 275t3 Kelkry Parkway I Plar�Ceview fee:
<br /> '`;�cr ���j�, Orona,MN 5�356 - _..._._._ :,
<br /> ` Kr,��,_ .��'p, 3�._..
<br /> _.:_� " - � 7'ot,�4�'ee:
<br /> Main. 952.-��i9-46Q0 - �ax: 952-249-4616 ws�tiv ci_r�mnn.r:�n.us
<br /> _.______m,.-.
<br /> —,�..___-- - _.....____._ ,,... _...___
<br /> This appkication form tnust be campteted in f��ll and al!requirecf inforrnation rr�ust be suEamitt�d.
<br /> �nCarnpiete applicaiions w�li be r�turned. (1'lease prirrf)
<br /> GEINERA�1�EF�RMATIC?IV:��_C_��., . ,
<br /> Job Site Address; ,.�:..� I � �..--1�J� 1' ._ �� :
<br /> _.__��-__.._._ _._ _-. _... ..
<br /> Wiil this be a Rarad�a#Hom�s; R�model�rs Sh casaa Ham�er oth�sr Disp[ay Horne? �'es [�No
<br /> N yas.�s�+:erH/evertt permit is requiret�'wrth Aolice�,t7��iarfinent and City Courtc.N approval 6p dr�ys prior tn(he e�v�e�rt. St.zultlo btes serv}ce wif/#re
<br /> rdquf�ed uniess applicartt de�nanstratos sta��i�nf an•sife parkirr�is as?aitabl�. Non-pe+mitt�+t�pvenf;will�r�t�e al/aws�ci:
<br /> CONTRAGTOFtJ AP LtCAA�I"�INFQRMATIC3N:
<br /> Nam�: p� r ,c�. < < �',.�, c.
<br /> 3""'1C V,tia Yi��3 �'�C'.�YYl C �.�,j Vl� �? _ I .4_¢,',1
<br /> .,......,..,....._. _.._.._....... . _ . _._
<br /> Sl�te Licerse# i � . Expirstion Ra#�e: � 3�._.'?-�!__�� _ _____
<br /> C�,�C�r�-�'lt��-_.....__ �
<br /> L��d Certffca4ioq Number �"��+..{.{.1 -� � �xpiratian Date:
<br /> ---- ._._...._.__.______
<br /> (far woslc on hames thaf were construehed privr fo 1978
<br /> Phone: (c�li} �'..s�i 2. �� ��----C��f � _� (Qffiae) �12-����-..� �.� �r�`�_-_
<br /> M�iling Address; ���c-; t`*1 ,t,t.. ��w-+�,�td� �� � ��r City:�'' ri' �fw"�Y" �IF': '����-
<br /> Gontaet P�rsort: j}.- _ c-,y j�,�v�..�,. ,�,� Applicar�t is:�"�On acto�l r9omeowner �c�Kieo��
<br /> �rnaif andror Fax. X:��. �P�i�ts���'.0 f1��Ytr"Gtfi•�- r�`�`__.._ '
<br /> P�tOPER"Y'Y'Y O'4N'[VER Ih1F0E2tu�AT10N:
<br /> IVame: `� �N .� f
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<br /> Pt�one(day}: ��_2:�1 -"�' l..W�. �,.:..__ ...___ {
<br /> r_ 1
<br /> Address: 1'-i'�� �E'�?f��' LG4.s' " ._..___���''�*1��v�s�-t�:,✓ �IP: ���t�'�.
<br /> � �-_..�-
<br /> Email artdfar Fax:
<br /> PFtC1JEGT INFORMATlON O�eraN pro�ect des�ription:�C�~-L -�'�.d 5ft �.. � i��(�i,K.l .�2-'vV�. '-� L���' �(�.��
<br /> �... ____..__._..... . .. .,, �,�.--,:__�--...
<br /> €TYP�a of Pr��ect: �_.� �. . �ltty d�frth movement rrsay alsa reguirey F, .-
<br /> i 1r
<br /> � Cl 000r(s) ❑Remodel G�Fire Damage i
<br /> !W!G{A�C1 sevie�r 8�permi#s: �4`V ' ��'
<br /> ` I Minrtehaha Creek W�tersh�d Dasinct(�1CW p�
<br /> � ❑Re-rc>oi,asp�ak (�Re��ir U Storm Datnage
<br /> i 1 f3202 Uli.nnetanka BEvd .
<br /> � _. ..... �
<br /> ; ❑R�-ro�,f,cedar [YJ Restaratiun U VVater Darr�age j D�epf�aven,MN 65331
<br /> ; ❑Re-roof,ather{speciiy) ❑Siding ❑Clther.4speciiy) � �'hQnQ� 9�2-471-0�9d
<br /> , Fax: 952-�47'� f168�
<br /> , �Win�w�s} j vvww,rn!nrtc�h?hT cre�tc,er�
<br /> ............. .__.,....,:. _ ..W.-•-- -_...__._ ....._... . _....._... ....:,__.. ......... _.::....._..._._._,...._.. � --_._,.__ . _ .__...._�
<br /> Estsmated Construction Valuatian af Project{excluding land) $ i���='�
<br /> APPLICANT ACKNQWLEdGEI�i6ENT:
<br /> _ _,_........----�--__�..,.._�.
<br /> • agrees to prov�d�atl inforn�ation required or requested by the Building�?epa�irnent;
<br /> • Ge�tifies that#he lnformation supplied is teue-and correat to ti�e best of his/her kr�ow9odge. "f't�e appFicant reongnizes fttai they are
<br /> soiely r�s.p�ns►ble for submitting a compf�te app{ication beirrg aware that upon failurc;Ya do so,1tr��taff hr�s�ao a![ernative but 10
<br /> reject it unt�k it is co�nplete;
<br /> � Same or atl of th�e informatioro that you are askec�tp p[nvide an t#7is appkic.atian is classified by State !aw as �ikher privat� or
<br /> � confi�ential. i'rivale data is informaticm which gener,�lly c�nnot be�iven to k�te public but can be giuen to ihe subje.ct�f th�data.
<br /> iConfidentiaf data is'inforr:tation r�t�ict� yenerally c;annot f3e ,yiven to either the public or tlle subje.at of ti�e data. Our�ucpose and
<br /> � infen�ect use of this infiarmation is iq annually update aur records an�recards of ather gouarr►m�nfal agencies re�uire�i by law. 1F
<br /> � _y ou�r�fuse ta suppfy ttre�n rm�tii�n the a��lrcat� ma nnt b�issueci +
<br /> _ _ __ __..... ___--._ ...
<br /> � �- -
<br /> Ap�ilicant's Siqna#ure�__._�''�-�-'���.t_ _._.�`�C.._:� Qate: ..._...��.��-- -��
<br /> Owi�er's Signature: I�ate: _..:.._ww._........_......._...,.
<br /> L�st U�dated:Ja�uary 2015
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