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02/09/2016 1 : 14 : 18 PM PAGE 3/004 Fax Server <br /> � <br /> ' City of �Jrono <br /> Building Permit APP����o�fo�Mainte�ance 1 Replac�arnant! Rernadel—Rosidential aNLY <br /> _ . . . . - .. - � ' �':. - - - R Permit number. �.0)(p—6(>1 O <br /> Maitlr+g Adalress= �. --i <br /> ���0 PO 8ox 66 Oate rec�ved: <br /> Crystal Bay,MN 55323-0066 <br /> Received by: , <br /> ���" Plan teview fee: �" <br /> � 2750 Keiley PsrkwdY <br /> y,� �� Orano,AIW 55356 Totel Fee: ' �� ° �, <br /> �'Q�CESH��� :�n Cf OI� <br /> p�: �2 24�48� F� 952 249-4615 <br /> Thts aPP�ic���m��a p leteci in fialt and aU required ir�fa�p nr�uat be subm�tted. <br /> {ncomA p I[c�tions w3U he ret�rn+�d- ( <br /> (�ENERAL lNFORMATl0A1: � � �� �ip�lL Y� No <br /> Job S[te Address� <br /> ,anerrt ar�cldy C�au�eP�'��a���D dre evanL sJ,t�de aus sanrire w�be <br /> Wifl this be a Pa��sm��x�°��°wcase Hom�or ottter p�sy ���Wm nat be allowed• <br /> rts�8�+�unr�s av��es s�er�w�,pe�►�s�a,�teare- n�R•aB7►r� <br /> COIVTRACTaR�A��CANT INFORMA'EION: <br /> Name: F�tpiration Data: <br /> State License# Expiration Date: <br /> Leaa certi�at�^�umber: orw 1sra <br /> (Mr worlc an���cartsb�rc�p� (o(fice) � . <br /> Phone: (� f City: 04 <br /> MBiUng 14ddress: aao o,u,) <br /> A►ppltcant is: Cantr'ador 1 �� <br /> Con�ct Pe�son: <br /> Email andlor Fe�c 1 ' <br /> PROPERTY ONMER i ORMA�O : a <br /> Name: •. <br /> Phane{day). �LNV � C�Y� Du f,� zIP: � <br /> Address: <br /> Email andlo�r Fax� <br /> n: p�y earth moveener�t nay atso reaWre <br /> PROJECT INFORNIP►Tt�N: Ovetatl ro ect descri �c�p�view�Pe��� <br /> Ty��ProJe� Fire lramage District(MCWD) <br /> ��5� p Ramode� a Mir�ehs►��reek wate�shed <br /> ❑Re�mot.asPf� ❑���� O Stotm Da�nage 15320 Mitmetanka BNd <br /> WE�r D�mage AAinnetonks,MN 55345 <br /> Restoradon ❑ '� Pfsone: 952h71-05� <br /> ❑Re-rcaf.ceds't��►} �x ❑p�her.(ePedfYl �ax:i 96��71-Q682 <br /> Re root. la���•�9 <br /> y ��$) <br /> �m�d Constructian ValuatMn of ProJect(�xcluding land} S <br /> ppp�,{CANT ACIU�fOWLEDGEMEN���u��hY��ui►ding Deparbmenk <br /> . p,qrees to prov(de aD inrom�ation requi <br /> . Cettifies that 1he atfartne�bioci suP a�������9�of h�'i��n fa�u e tso do soe,$iha�staff has no��btst�o <br /> ��y�ponsible tor submitan9 P <br /> rejed it ur►nf it ts c8mpleta, State law as either private ar <br /> • S�ne ar ell of tl�e intormation that you are asked to Prov�on tliis applicatlon is classifi� bY nr�ta tl�e subjsd of the da1a. <br /> confidardlal. Private c�ta bs ir�torme�on��'S�e�y canr�ci t�given io the puWic but can be g' <br /> �ahid�generattY cannot be g�►en�o eitt�r the publ�c or tlte su�o�g d��A�r d by�law� <br /> Con�dentiat deta ia iniomiatlon aur tecorda erui�rds of ath�g�m <br /> iMended�e at ltds Infomration�tn artnuaNY�P�� <br /> refuse to �►e ENorrnal�an the icatio�m not be iss�ted. [. <br /> u .s��n u. -- �2t8: <br /> ApPlicant's SigneSure: � � <br /> �u <br /> puune�'s Stgnature: <br /> �uS�'�� 4►�+u►► Date: _����! <br /> tast ut�ea:3an►�+2a9s <br />