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<br /> Building �Permit Appli'cation �far Internal Work
<br /> (windo,ws, doors,�sidin , re-roof, etc.)
<br /> MaJling Addriiesar a ' ', ,: Psrmit number: ��-�
<br /> //���� PO BOx 66
<br /> ��/Q` � Crys[ai BaY� MN"393Z3-0066 ; ," I�ate r�oeived: _� �� ..�GYD
<br /> � � ..,,1' �a SbAet Ac�dress: � Received by: .�i��r�
<br /> 2750 kell9y Paf�(way; , �J'�...
<br /> - - E' I lan re�iew fec: ,
<br /> '�i� p9.�; , Orono,MN 55366 , �� - •••
<br /> � � Total Fee: 5�� /�
<br /> Main: 952-248-4900 Fax: 952-248-4616�, �nrww�i;�Y0ilo.mn_us� ���i vv
<br /> This application fvrm must be completed in,full and`all requtred Informa[ion must be submitted. � ��
<br /> Ihcvmplete eppllcations wfll 6��;�urr���!'. (P/c��se printJ
<br /> GENERAL INFORMATION: - `
<br /> Job Sit9 Address: ��� /'(f0�1���Ll� f(� � • �/ /l7✓'(� GG
<br /> Will this be a Parade of Homes, Remodelers ShowCase Horrj'e'or othet Di lay Nome? Yes No
<br /> —� ' ..—
<br /> 11 y�s,a spqClA/CVCnt p6nnit ie requfrod with Rolice;pe�uarhi�vntppd Cky Counyil epprbv�eil bU doy�prfer M thc ew>nl. shuftle Dus StiIWc;9 Wlll DB
<br /> rr+quired unkra�ar epplir,�nt dmmo►kstiqtee!6Gf17CICr�COnc�N{i9 ptrlltlilp/S;mVa11a01e. NOA�efmitted events will nol be allowod.
<br /> CpN'1'FZACTOR/AI'PLICANT IN�QRM74'ryONI ` `� �
<br /> Nams: .s��r �V i��j'k��GY �� � .,s,
<br /> 5tate�icenee# ;T Expirat�on Date:
<br /> Phone: , ••. (�cc� ��— —•. ...-
<br /> .. . (cell) _
<br /> Malting Address� �� 'City: � ��p:
<br /> Contact Person: ,� _.�_,qpplicant is, Contr�ctor / Homeowner �cir�ie one���
<br /> Email andlor FSX: ,
<br /> PROPERTY OWNER INFO l TI�1: , . �
<br /> Name: � 5 � �/I�j1/� �
<br /> t�hane (day): - • •�••- .
<br /> Address: O !/� � City:,JY1ddN/� ZIP: '✓�t��Gf
<br /> kmail and/pr�ax � ,�
<br /> PROJECT INFORMATION: , ,
<br /> Type o ro ect: �� �� � �1 �Any earkh movoment may roquir��
<br /> ❑ boor(s) ❑ Romodel � -" C;;IlWatdr 17amego Y '� , � . MCWD revlew 1�perrflits
<br /> �Window(s) �]Repair � � ' f, � Minnehah2 Creek Watershed District(MCWD)
<br /> , C.l Sfomi DamaB� { � 18202 Minnetonka BIvC
<br /> " Deeph�vsn, MN b5391
<br /> ��iding [7 RestorattQh K ; ' I. �other:(spe�ify) . Phone: 952-a71.0500
<br /> CJ Ra-roof , � FaX; 952-471-OBa2
<br /> ❑Fire�ema�e�'� /�(S'U,li•1�J'�i.�/✓ uiww,minn h�„s ralla�oroAk.orn
<br /> Overall project Descripllon: � �fJ
<br /> �Estimated Conalruction Valuatlon�or'� Pro)ect(ezcluding land)' ls^OdFI ' �—
<br /> � , . / • • . . _
<br /> APPLICANT ACKNOWI.EDG�MENT: � � - �
<br /> -�� Agrees�to provide al��nlbtmation fequireq or requested by the Building Departme��:" ' "�—�
<br /> . Certifios that the infonnation supplivd is vue and correct to tne best af hielh�r knowltdge. The�pplicant reco�n�e�tnai they
<br /> are solely nesponeiDle Por submitting a Complete application being aW�re that upoll failure to do eo, 4he ataff has no alternativo
<br /> but to rejeot it until it is complete; ,
<br /> • Some or all of th� information tha�you are aSked [o provide on this applic:ation �e classifietl by S�[c� 18W as either p�ivate or
<br /> confident�al. Private data is iniormstion whioh gcnerally cannot De piven to,the public but cen be giv�n to the sub)ecn or tne
<br /> data, Co��fldential data is intbrmation which generally cannot be.givep ln,eithe�the.public or the subject of the data. Our
<br /> puroose and intendod use of this information 18 to annually update ouc record�qrid r�coinlg of other Qovel'nmentAl agdnciee
<br /> ._ _�uirep bV law. 1i ypu refuse to au I the information,th�a Iicatl�on_md�_not be issued. _ _ _
<br /> AppllCeht's Signature: -
<br /> . ; _epate: ��.
<br /> , + ' t ��,. 1:t� ' I . •-
<br /> �.ast U�,datncl: 05•04-ZOOJ , I ,: + ` , .� '
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<br /> Td Wd£S:zti 0S0z Sti 'adti �b0968L£9L:: 'ON Xti� ._ 0� A91MOcl�: WOd�
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