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MAY/12/2016/THU 04: 11 AM FAX No, 952 854 4909 P, 002 <br /> _ �1'�/ Of ��'Q110 <br /> Building Permit Applicatian for Maintenance/ Replacement/ Remodel -- Residen�ial:ONLY <br /> ji.e.windows, doors, siding, re-roof, etc.— NO STRUCTURAL EXPANSlQN) <br /> ��O Mailing Address: Permit number �_ <br /> PO Box 66 <br /> Crystai Bay,MN 55323-U066 Date received. — �D <br /> � <br /> Street Address: Received by: <br /> �� � 2750 Kelley Parkway Plan review fee; <br /> G Orona,MP!55356 �� <br /> `���5���� Total Fee: ��� <br /> Main: 952-249-4600 Fax: 952-249-4fi16 www.ci.arono.mn.us <br /> This application form must be completed In full and all required information must be submitted. <br /> lncomplet�applications will be returned. (Please print) <br /> GENERAl.INFORMATION: �,S.Yo �V� <br /> Job Site Address: � O Qt � <br /> Will this be a Parade of Homes,Remodelers SHo case �ome or other Display Home? Yes No <br /> lP�res,a spe�;�l�vent pe�mit is�quired wifh Police Dspartmenf and City Councr7 approva!60 days prior to the event Shutde bus servlce wfll be <br /> required unless appllcarrt demonshates suAfcienf on�ite parking/s avallable. Non permitled events wlll not be al/owed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# pella Northlazad Expiration Date: <br /> Lead Certification Number: 15300 25th A�re N. Ste I00 Expiration bate: <br /> (for work on homes that w Plymottth,�N 55447 r <br /> Phone: (cell) Y,xc#BC645090 Pkx. 763/745-1400 FCe) 4 S��� y s • � �y 3 �1 d Cl. <br /> Mailing Address: City: ZIP� <br /> Contac#PQrson: Applicant is= ontra / Homeawr►er (ciroie or�) <br /> Email and/or Fax� �, b cl; s � d l a�� P�u n�� �� � , <br /> PROF�ERTY QWNER FO AT[ON: <br /> Name: Q � � ! � -�� �' <br /> Phone(day)� ��� �a S, L y <br /> Address: Q l City:�o�1 ��l d z1 P: �$ � � ` <br /> EmaiE and/er Fax: <br /> PRdJECT INFORMATION: Overafl praject description: <br /> Type of Project: My earth movemerrt may afso require <br /> MCWD review 8 ernits: <br /> O a�Ks) ❑Remode( ❑Fire Damsge � <br /> ❑R�roof,asphait ❑Repair ❑Stomn Damage Minnehaha Creek Wster�hed bis#rict(MGWQ) <br /> 15320 Minnetonka�1vd <br /> ❑Re-roof,�edgr ❑Restoration ❑Water Dam�ge Minnetonka, MN 55345 <br /> Re-roof,othe� a Ac Phone: 952-471-0590 <br /> ❑ ( p � ❑ Siding ❑Other.(specify) F� g��.471-0682 <br /> �Window{sj� www.minn creek.or <br /> Estimated Constructtan Valuation of Project(excluding land) $ � <br /> APPLfCANT ACKNQINLEDGEMENT: <br /> • Agrees to provide all informatlon required or requestod by#ie Building Department; <br /> . CertEfles that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible fvr submitting a complete appllcation being aware that upon failure to do sa,the staff has no aliemative but to <br /> reJeCt It until it is compiete; <br /> . Some or all of the information that you are asked to provide on this application is classified by Sta#e law as either prlvate ar <br /> confidentiai. Private data is inforrrtation which generaily cannot be given to the pubiic but can be given to the subject of the data. <br /> Confidential data is informatlon which generally cannot be given to elther the public or the subject of the data. Dur purpose and <br /> intended use of this informatlon is to annually update our records and records of other govemmental agendes required by law_ if <br /> u nefi,se to su the information e a ' tion ma not be issued. <br /> ApplicanYs Signature: �~ pa�; J� �I� 11 L <br /> Owner's Signature; Date: <br /> Last Updated:January 2016 <br />