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` ' lJ�'N"- <br /> 1 J <br /> � l Ci�T� - —— r+.-....�.� � _ n q.'�� 11� ���� <br /> BUILDING P r��� l� - N'����:� c��� �� � <br /> ��.: n u.� v�.,r�w� ��,., �3�7� <br /> FOR NEW STRt � �' / <br /> � °� � <br /> S 7�e���� , �o l3-DD�7 <br /> O�T Mailing Address: <br /> � 1 y PO Box 66 j )� � � <br /> � Crystal Bay, � "''YL�C.C,'"�l�L�� ���/j`t����'W�j��,_ --(g— �3 <br /> StreetAddress:' TJ`� � <br /> ��, � 2750 Kelley I � �j <br /> �' Orono, MN 5 <br /> `qkBSH04� ao�3-o0� �' <br /> Main: 952-249-4600 Fax: 952-249-� ,, �( �i 1�' " - �,'' <br /> This application form must be comple � u� ��'�'' � C.-� �mitted. <br /> Incomplete applica �/j,(� � -� <br /> GENERAL INFORMATION: , Q <br /> Job Site Address: �� !,� � �'�' a a � ��� /J(p ,J��' <br /> Will this be a Parade of Homes, Remodelers Sr 3 3� � Yes No <br /> If yes, a special event permit is required with Police Department ar �s service will be <br /> required unless applicant demonstrates sufficient on-site parking is / � /� <br /> l� � <br /> CONTRACTOR/APPLICANT,.I NFORMATION• <br /> Name: ,1 Y C�� 3 f��c.-�c�-����, - G�(�� L� <br /> State License# _ ��J��� � Z 3/ /� <br /> Phone: cell j� - ' �Q•�713 - <br /> Mailing Address: � � �j� �(5 � : �� �l( <br /> Contact Person: �,��,,,,�firc`� G e� �r (Circle One) <br /> Email and/or Fax: ' <br /> PROPERTY OWNER INFORMATION: . , <br /> � <br /> Name: .1�S Y �c•� s�r~��c� �,g� L L <br /> Phone (day): 67 2- � 7r � f�t ZI P: S S �t / <br /> Address: ,3�tS- 2 i f-'r l, •��� L� Cit : l� ��t <br /> Email and/or Fax Gi!r y ca�s �'uC �ztC��t���.�v«-r <br /> ���:HITFrz ENGINEER INFORMATIQ�I: <br /> Name: �vct� /3r�xG(l.�y <br /> Phone (day): 763 --3r v-- 34S G <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal 8� <br /> Water Supply <br /> ,�Z(.�New Construction �Single Family with �Residence <br /> ❑Addition attached garage ❑�arage/Accessory Bldg. �Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> **Any earth movement may also require ❑ Commercial ❑ Other(specify) <br /> MCWD review 8�permits. ❑ Industrial Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (speCify) <br /> 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding iand) $ ���.� �O� <br /> I� ,;� . <br />