HomeMy WebLinkAbout2015-00658-voided May 25 15 07:OOa Tom Campion Construction 763-479-6755 � p.1
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Buiiding Permit Appli�ation for Maintenance ! Replacement 1 Remodei
(i.e. windows, doors, siding, re-roof, etc. �- NCl STRUCTURAL EXPANSI�N)
�O� Mailinw0 Qx 66� � Permit nuCnber � —Q��/ !J
� Crystal Bay,MN 55323-0066 �/ Date received: �+� z�P —�S
Streef ACdness: � Rece��ed by:
y� �' 2750 Keft�y Parkway 1'1 �ian reviewfee: ;�
� O�one,MN 55356
��'R�SHO�`'t ��� ratal Fee � �� �.�5
Main: 952•2d9-46UQ Fax: 962-248-4�616 �w�vsi.orono.Qn.us
This applica;ion form musi be completed in fuil and all required information mu submitted.
Incomplete applic�atfons wfll bQ retumed, (�►eas�print) �
GENERAL INFORIAATION: •
Job Site AQdress: ��a d �j" `
Wiil this be e�arede of Homes, Rema ele+'s Showcase Home or other Displaty e Yes No
1�yes,a speGs/evenf permll!s raqu/ned wifh Pa'�Ce DepBrimeni end Cify.r,aunc�l eporovaf 80 dtiys !o t nf. SRufHe bv8 service w!k be
requ�d unjess a�plic8rn demonsb'aAss sufrrc%ent on-s�e parkrng is avaAsbl `p t� nts will nof be eUowed. ��n/
CONTRACT�R1APPl 71NF0 ATION: '` ` '
f�ame: � �
State License# Expiratio�Date: p
Lead Certification PJumber. Expiration Da'.e: p ''�'
(ior worik on homQs tha�vvQre c°�ructed r tn f 8 cy ,(�� r�—
Phone: (cell) rGJ�;s�� (o�ce) �� � ,/ `(�/ 3
Malling Address: �g. C� : Z�P:
Cor�act Persan: � � �� , AppliCant is: Contractor / Hornevwner rc��oon��
Ernail and/or Fax: � �g �
PROPERTY aWNER f FORMATIQd.; '�
e
Name: � ✓ � �
Phone(day)' J ( �- '�( ,
Address; ,;� `' � City:(, Z!P'
Em�il and/or Fax:
PRO,iECT INFORMATIOIV: Over�U r ' c:desui tion:
Type of roject: Any earth�no�ement may also requ�re
� ❑ Door(s) ❑Remodel ❑Fire Darnage 1YICWD review S}�ertnits:
❑ Re-raof,asphalt ❑ Repeir ❑Storm Damage Minn�ha�e Creek Watershe0 Distri�t(MCWD�
15320 Mlnnstonka Blvd
, ❑ Re-roof,cedar ❑Res tion ❑Watsr Oamege Minnetonka,MN 55345
j �Re-roof,otfie�{speclfy) ❑S' ng l]Other.(speaityl Pfione; 952-471-0590
Fax: 952-47�-0682
�W indow(s) www.minn ehahacre ek.orrm
Estimated Construction VaJuatlon of ProJect(exctuding land) �
APPLTCANT ACKNOWLEDGE�fEENT:
. Agrees to provide ail infarmetlon requlred or requested by the Bullding DepaRment:
• Certifies that ths infortnatiori supplied is In�e and correct to the best af hisfier knouvledge. The applica�t recognizes that they are I
solely respansible fnr submitting a complete apofication be�ng aware that upon faiiure to do so, the stafl has no altematFve but 10 `
r+eje�t it unti!ii is camplete;
• Some or aU ot the intcxmatlan S118t y0u are 6SkAd to ptOvide on this epplicaliort is Gassified by 5tate law as eilhEr private O� I
ao�fidant;aS. Private tlata is iMermation whlch gerterally cannot be given to Iha pubfic but can be given to the subjecl at the dala.
Confidentiat data Is infarmalton which ge�erally cennot be glven to either th0 pubffc or the subJect of the data. Our purpose end
intended uge oi this inforr.iatior+is to annuall ate our records end recorcis Qf other govemmen�at egancies required by law. If
ou relvse to su I the irdo 'an the � tion m8 not be issued-
Appfi�anYs Signature: Date_
Owner's Signature: Date:
Last Updated:,lanuary 2015