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e _. <br /> �1�/ Of ��'Ot10 <br /> Building Permit Applicafiian far tVlaintenance I Renovation <br /> (windorn►s, doors, �iding, re-roof, etc.) <br /> ��� MeJlfn��8ox BS� Permi�number: d/7—�7 <br /> � Q Crystal Bay, MN 55323-0066 Date r�eceived' — — <br /> �r� :� �, StreetAddress: Received by: ��/,t.f <br /> { 2750 K�Iley ParY,way �^7 <br /> �, ` • Plan revtew.fee� � <br /> �'�,�,��,�� Orono, MN 5535fi � � , �� <br /> -- 7'a#ai Fee_ � <br /> Maln� 952-248-4600 Fax: 952-249�616 www.cl.arono.mn.us <br /> This application farm must be campleted in full and a1i required informatlon rrsust be subm's��d. <br /> Incdmp�ete appllca#lons wi1[�e returned. (Pleese printj <br /> GENERAL INFORMA7IQN: u�� �d �� <br /> Job Slte Address: 1 <br /> Wt[)this be a Parade ort Homes, Remodelers Showcase Home or other Display H�rtte? Yes No <br /> lf yes,a speciaf event p9rmft Is requfred w/th Palice Deparfmebt end Clty Counol!apAroval 60 days priaY to th9 9vent- Shuttl�bus servfce wifl be <br /> rgqulr�d untess appfic8nf demolistf'�tes sCdi97Gl�nt onsile parking is avpi(abls. Non�9rmltl�id evertts wilf nof be allo�ved. <br /> CONTRAGTQR!APPLICANT INFORMATiON: <br /> Name: � ck\ 'AY�,�.'fS2�7 <br /> State �icense# �.13p�g� �xpiration Date: � j 3� <br /> Lead Certifir,�tion Number: (`j�T_ a�a S3 -_t, Expiratian Date. <br /> {for worls an homes th�t w�re canstncfed prlor fo 1978 <br /> Phone: �5�-' a�(0�}-�•0 r (office) (celI) <br /> Mailing Address �• �� �je� Cify: ; Q, ZIP: SS t � <br /> Contact Person: Appli�nt is: r / Horrteowner �ci�ia on�) <br /> Emaii and/or Fax; <br /> PROPERTY OWNER 1N�OFtMATf�N: <br /> Name: ��.55 i C.Cv LL1:�►�O a.a,� � <br /> _ _ _. <br /> Phone (day): �lo�"a�� �����j( <br /> Address: � City: Z[P: <br /> Email and/ar�ax <br /> PROJECt IN�4RMATION: <br /> Type of Praject� Any earth rrtovement may requlre <br /> [� E1oor{s) ❑Remode( �F��g pamage MCW�}review 8�psrm�#s: <br /> Minnshgh�Creek Watet'shed Dlstrlct(MCWD) <br /> �j Re-roaf, asphali []Repair ❑Storm Damage 1$202 Minnetonka 8t�d <br /> ❑ Re-roof,cedar ❑Restoratlon ❑Water Damage Deeph�ven, MN 5539� <br /> Phpn�: 8b2-47'E-0590 <br /> ❑ R4-rpof,pther(spactiy} ❑S!d[ng Q Ofher:(specify) Fax; 952-471-0$82 <br /> [�WEndow(s) www.minnehahacre.e.k,ora <br /> �verall Praj�ct Descrlptlon: (G.c.c a �^-'���' Wl..� �C X��f► <br /> Estimated Cflnstruction Valuation of Prnject(�xclud#ng Eancf) $ <br /> APPLtCANT ACKNOWLEDGEM��T: <br /> • Agrees to provide a3I information required ar requested by the euilding Depar�ment; <br /> . Cert'if'ies ifi�t#he infprrnation supplied is frue and correct ta the best of his/h�r knowl9dge. The applEcant re�ognizes that fhey <br /> ar� soiely responsible for sUbmifting a cortlplete appllCetlon being ewere thet upon faiEure to do so, the siaff h8s no 8itemative <br /> but ta reject it until it is compl�te; <br /> . SQme or ail of the Inforrr�ation that you are asked to proVide on thPs applic�tlon Is classlfled by State law as either private or � <br /> confldsntlaL Pr�vate data ls 1nfArmatlon whtch generalty cannot be give� to the public but can be glven to the subJect of the ( <br /> data. Confidentiai data is ir►form8t�on w�llch generaliy cannot be gfven to eiiher the public or the subjeet nf the data. Our <br /> purpose and intended usg af this inform�tiqn is to annualfy update our records and re�ords of oingr governmental sgencIas <br /> re uir�d b IaW. If ou refuse to su I the irtfqrmation ihe a Ifcaflon ma not be issued. <br /> Annlicant's Sianature: � Date� ��E1��l� <br />