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J�J�?,-1 E;!2'�I��%TuU C'4? .^ °i�'': Elder Jones Bui lding FA:� Tdo, °F? 854: 4J0� P, 002i 003 <br /> , <br /> � . <br /> �It�/ Of 0�"0�10 <br /> Building Permit Applica�tion for Maintenanc�/ Replacement/ Remodel — Residential ONL.Y <br /> {i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> �Q�Q Ma111ngAddress: Permltnumber: � . � �U� <br /> P�Box 6fi <br /> Grystal Bay, NEN 55323-0066 Date received: !v -% 7 /(,� <br /> � � StreetAddrQss: Recelved by� - <br /> y� 1� 2750}Celley Parkway Plan review fee: � <br /> t G OronQ, MN 55356 <br /> ���5����� Total Fee: � �� �� <br /> Main: s52-24s-4soa Fax: 952-249-4616 www.ci.�,rQno�„mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incorrtplete applications will be returned. (Please prinf) <br /> GENERAL INFORMqTION: � u � O �r I,( e <br /> Jab Site Address: -[ [Y a r"fi/J ✓,b�r �,� <br /> Wi11 this be a Parade of Homes, Remodelers Showcase Home or athar 171splay Home? Yes No <br /> If yes,a specisl event permit is required v��rfh Police Departmenf and City Counci!approva!60 days prior to the event. ShuttlQ 6us sarv(es w(ll be <br /> requlred unlass appllcant dernonsfrafes sufflclont onsfte palking Is avaNabla. Non-permltfad AvanPs w/II Irot be allowed, <br /> CQNTRAGTQR/APPI.ICANT INF�RMATION: <br /> Name: Pella Northland <br /> 5tate License# E,xpiratian Date: <br /> Lead Certification Nuinber: X5300 25tI1 A,ve N. Ste lU0 �xpiration Date: <br /> {for wa-k on homes that v ��Y��Out�,MN 55447 <br /> Phone: (cell} Lic#BC645090 Ph. 763/745-X400 ffice) <br /> Mailing Address: Git : ZIP: <br /> Contact Person: Applicant is� Contracto / Homeowner (c�r�ia ona� <br /> EmailandlorFax: �, cdi S � Cl�el 4and5_ P� M <br /> PROP�RTY OWNER INFORMATIO : <br /> Name_ �! 0. �0 /�"1 (k <br /> Phone(day)� G 1 7 3 4 ` - S 3 9 �f n <br /> Address: y y 6 q /1!a r�i� �h�!G v/ City: �b �/1 d Z1P: 'S S� �y <br /> �mai1 andlor Fax: � <br /> PROJECT ifVFORMAT(ON: Overall project description' <br /> 7ype of Projact: Any earth movement may also require <br /> � Doar(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-raof,asphalt ❑ Repair ❑Storm pamage Minnehahe Creek Watershed District(MCWti) <br /> 15320 Minnetonka Blvd <br /> (] Re-roof,cedar ❑ Restoration ❑Wat�r Damage Minnetonka,MN 55345 <br /> �f Re-roof, other(spocify) ❑Siding ❑athor: (specify) Phono: �52�73-0590 <br /> Fax: 952-�71-0682 <br /> `�Window(s) www,minnehahacreek.orq <br /> Est►mated Construction valuatlon af ProJect(exclud�ng land) $ <br /> APPUCAN7'ACKNOWL�DG�M�NT: <br /> • Agrees to provide all information required or requested Uy the Building Departrnent; <br /> • Certifies that the information suPplied is true and corr�ct to the best of his/her knowledga. The applicant recagnlzes th�at they are <br /> saleEy responsible for submittinJ a complete application beinn aware that upon fallure to do so,the staFf has no alt�mative but ta <br /> r�ject it until it is camplete; <br /> • Som4 or all of the information that you are asked to provide on thls appllcatfon is classlfled by State law as eith�r private or <br /> confidentiai. Private data is information whieh qenerally cannot be given to#he public but can be given to tho subject of the data. <br /> Confidenfial data is information whlch qenerally cannot be glven to either the public or the subjact of the data. Our purpose and <br /> intended use of this information is to annually update our reeords and records of other governmental agancias required by law. If <br /> ou refuse to su I the]nformation,the a Ifcatlon may not be issued. <br /> Applic�nYs Signature: � p�te; G f� G L � �' <br /> Owner's Signature: Date: <br /> Lask Updated:Januery 201 B <br />