Laserfiche WebLink
May 25 15 07:OOa Tom Campion Construction 763-479-6755 � p.1 <br /> — _ .- - -_- _,.�_ ,_.._.. �.1 i, ur u+�urvu v�� PAGE 0I/@1 <br /> f �'4110 ���`'� �5 <br /> C l�)/ Q � � <br /> Buiiding Permit Appli�ation for Maintenance ! Replacement 1 Remodei <br /> (i.e. windows, doors, siding, re-roof, etc. �- NCl STRUCTURAL EXPANSI�N) <br /> �O� Mailinw0 Qx 66� � Permit nuCnber � —Q��/ !J <br /> � Crystal Bay,MN 55323-0066 �/ Date received: �+� z�P —�S <br /> Streef ACdness: � Rece��ed by: <br /> y� �' 2750 Keft�y Parkway 1'1 �ian reviewfee: ;� <br /> � O�one,MN 55356 <br /> ��'R�SHO�`'t ��� ratal Fee � �� �.�5 <br /> Main: 952•2d9-46UQ Fax: 962-248-4�616 �w�vsi.orono.Qn.us <br /> This applica;ion form musi be completed in fuil and all required information mu submitted. <br /> Incomplete applic�atfons wfll bQ retumed, (�►eas�print) � <br /> GENERAL INFORIAATION: • <br /> Job Site AQdress: ��a d �j" ` <br /> Wiil this be e�arede of Homes, Rema ele+'s Showcase Home or other Displaty e Yes No <br /> 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 <br /> requ�d unjess a�plic8rn demonsb'aAss sufrrc%ent on-s�e parkrng is avaAsbl `p t� nts will nof be eUowed. ��n/ <br /> CONTRACT�R1APPl 71NF0 ATION: '` ` ' <br /> f�ame: � � <br /> State License# Expiratio�Date: p <br /> Lead Certification PJumber. Expiration Da'.e: p ''�' <br /> (ior worik on homQs tha�vvQre c°�ructed r tn f 8 cy ,(�� r�— <br /> Phone: (cell) rGJ�;s�� (o�ce) �� � ,/ `(�/ 3 <br /> Malling Address: �g. C� : Z�P: <br /> Cor�act Persan: � � �� , AppliCant is: Contractor / Hornevwner rc��oon�� <br /> Ernail and/or Fax: � �g � <br /> PROPERTY aWNER f FORMATIQd.; '� <br /> e <br /> Name: � ✓ � � <br /> Phone(day)' J ( �- '�( , <br /> Address; ,;� `' � City:(, Z!P' <br /> Em�il and/or Fax: <br /> PRO,iECT INFORMATIOIV: Over�U r ' c:desui tion: <br /> Type of roject: Any earth�no�ement may also requ�re <br /> � ❑ Door(s) ❑Remodel ❑Fire Darnage 1YICWD review S}�ertnits: <br /> ❑ Re-raof,asphalt ❑ Repeir ❑Storm Damage Minn�ha�e Creek Watershe0 Distri�t(MCWD� <br /> 15320 Mlnnstonka Blvd <br /> , ❑ Re-roof,cedar ❑Res tion ❑Watsr Oamege Minnetonka,MN 55345 <br /> j �Re-roof,otfie�{speclfy) ❑S' ng l]Other.(speaityl Pfione; 952-471-0590 <br /> Fax: 952-47�-0682 <br /> �W indow(s) www.minn ehahacre ek.orrm <br /> Estimated Construction VaJuatlon of ProJect(exctuding land) � <br /> APPLTCANT ACKNOWLEDGE�fEENT: <br /> . Agrees to provide ail infarmetlon requlred or requested by the Bullding DepaRment: <br /> • Certifies that ths infortnatiori supplied is In�e and correct to the best af hisfier knouvledge. The applica�t recognizes that they are I <br /> solely respansible fnr submitting a complete apofication be�ng aware that upon faiiure to do so, the stafl has no altematFve but 10 ` <br /> r+eje�t it unti!ii is camplete; <br /> • 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 <br /> 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. <br /> Confidentiat data Is infarmalton which ge�erally cennot be glven to either th0 pubffc or the subJect of the data. Our purpose end <br /> intended uge oi this inforr.iatior+is to annuall ate our records end recorcis Qf other govemmen�at egancies required by law. If <br /> ou relvse to su I the irdo 'an the � tion m8 not be issued- <br /> Appfi�anYs Signature: Date_ <br /> Owner's Signature: Date: <br /> Last Updated:,lanuary 2015 <br />