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Ci�y of C�rc�r�+�
<br /> Building Permit Application far Maintenance / Replacement I Rent�vativn
<br /> (No structural expansion. Only windows, doors, siding, re-rc�of, etc.}
<br /> Matling Addre.�ss: �� _ I�I '
<br /> �-y�'�-���� � PO 8ox 66 ' F'ermit numbe�: t
<br /> � ' Crystal Bay,MN 55323-C}066 � Uate received: ��-'�v—�
<br /> � Stre�t Address: Received by: �,�/�
<br /> � � � i 275{?Kelle Parkwa
<br /> f `t f x .�. Y Y Pian review tee:
<br /> �. �y .��� �`�.�� t3rono.MN 55356 �
<br /> AFiNI���.- �
<br /> �' _ . �rD��c��e: C � _ cj�
<br /> Mam: 952-249-460D �ax: 952-2�9-13616 ,n�ww.ci.oro�,o mn us �
<br /> __ _ __ ' _�._.._.�,�.....�___._. __�/rG�__..//-�/
<br /> This applicatian form must be completed in full and al1 required infnrmation must be su mitted.
<br /> {ncomplete applications wiil be re#urned. (Piease prrnt)
<br /> GENERAL INFORMATION:
<br /> �� , � `"
<br /> Jab Sfte Address. _ j � � ��4 '�.� _ � , r �;° °,��_ i_� �. �_�.�;
<br /> Wiii this be a Parade of Hames, Fiemodelers Shr�wcase Home of other Display Home? ��]Yes —�,No
<br /> Il yes,a spa�rat event permrt rs requrr�d with f�otr`r.e Oep�r(mer>t ttnd City Counci}approva!60 days priar Co fhe event. Shuttie bt�s senr7ce wi118e
<br /> r�quveel unte:�s applicanP ciarr�rc�nstrafes sttNr'ei±�rrt an•s;le parking is avaitable. Non-permiited sv�rrts rvilt rrot be allawed.
<br /> CON?'RACTQR J APPLICAN'C INFORMATION:
<br /> Name: ` � ` y
<br /> :k � �.— j c i � � '.—'.. .._..� l'. \ . t,,,�\�. � �I L.� �'- __
<br /> State �icens�� • - ��- � " �Expiration Date: �,- '"� � .� �(�
<br /> _�_ ._,. �._ �_ __._.. _ , ..
<br /> Lead Certitication Nuniber ...�� r �',, _�'�i__; _ � ExpiraCion Date =� - �j�, • � ��,,� � ,,
<br /> (for work on hames that were constructed prior to ?978 _^
<br /> Phone: tceli) �__..________ (office) ��;� -` ,; - ,'��; � , -� �`�. <:t��
<br /> Mailin Address: �"`.r..^ �; � � - � • � r � -�-��
<br /> 9 , �i�[ C 7 �� � C�� �t- u � l 1 r �L-r City: �'x���;� a��t�,���>ZIP: ...�{_i��x. _=i
<br /> Contact Person; -�����, ��t. ��-,<;,. Applicant is: �c�ntractor °H meowner �cko�o„��
<br /> Emaii ancJ/ar Fax: ` , , ��� ,; , t �.,.� �;t, � -._. ..
<br /> c r .. l�:�::15:_.Ct..t� � ,�'� �`�
<br /> � �_ _ __._ . .��°r��,
<br /> i'Rt�PERTY OWNER INFORMATION:
<br /> Name: �� x��_::_.°� -`---_� '�
<br /> Phone (day): 1`-� � �-t��_._�
<br /> ..�� �1,.
<br /> Address: ' ! �� ��d � � - �' Cit ,����,- t.,�.. ZfP� ��"' c�: �°��-
<br /> ,- ._
<br /> _�..����...._�.. ��� e •�;����:� 1..�'1 Y �1,��i� � � _, _3`�1
<br /> Email andlor Fax:
<br /> PRt?JECT INFORMATtQN: �verail pro�ect description: ��� ` ;��� �,' #. , �> � � �, �. �,: � ��. ' ,�..,:� �� ,, `, ; � � ,'�', �"�
<br /> _____, _ _----
<br /> ____
<br /> Type af Project� j Any earth movem nt may a4so r�qui�e
<br /> MCWD review& err�rits.
<br /> I p
<br /> ; ❑ DoorCs) ❑Remor�di ❑Fire Damage �
<br /> � ❑ Re-roof,asphalt �Repair ❑Storrn Damage � Minnehaha Creek Watershed District{MCWD)
<br /> � � 182(}�A�linnetonka B{vd �
<br /> i ❑ Re-roaf,cedar ❑Restoration ❑Waiar Damage ; pe�phaven,MN 55391 �
<br /> i ❑ f��-raoE,ather(specify) ❑ Siding ❑Other:{speclfyj � �hone: 952-471-0590 �
<br /> Fax: 952-471-0682
<br /> ; ❑Window(s) www,rr�innehah�crQek c�� �
<br /> �_...._.___ _.__.__ --..._______ ___ ______�__._..,,�..__.__ —_,__�
<br /> Estimated Construction Valuation of Project{excluding land) $ ti-�,�^,�2';•`�ut`
<br /> APPLICANT ACKNOWLEOGEME#�T;
<br /> • AUrees ta;�rav�de ail inforrnatic�r� requir�ed or requested by the Building Department�
<br /> • Certitios that tha iniormacian suppiied is true and correct to the aest of histher knc���rEedge. The applicant recognizos that they are
<br /> soEely responsibfe for submitting a complete application tteing aware that upon faiCure to do so, the stafl has no altemative bu1 ta
<br /> : reject it uniil it is complete;
<br /> ', • Some or ail of the information that you ar� asked ta provide on this application is classified by State !aw as either private ar
<br /> ' c,onfidential. Pnvate data is informatio�which ge�eraily cannot bs given to the pu6lic but can bo giu<sn to the su�ject of the data.
<br /> Confidential data is intormation which ganerally cannot be given to either the public or tt�e subject ot the dat�, C7ur purpose and
<br /> ( intended use ot this informaGon is io annual(y update our records and records of other gcsveenmental agenci�s required by law. If
<br /> � you refusa to supply the tr�formation,the appGcation may not be issued.
<br /> Applic�nt's Signature: �" ; ' `� � �' ��� i �! ' 'C:_ �. ����'�� , Date:� } �, - 1 t�'� l �.�
<br /> Owner's Signature: Date:
<br /> Last Up�ated:03r0612013
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