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Oct 0311 02:OOp Gates General Contractors 7634387710 p,1 . � / ' of Orono �� C�ty Building Permit Application for Maintenance I Renovation (windows, doors, siding, re-roof, etc.) Mail► I�ddress: � _ ��J I Permit number. / �Q�, PO Box 66 O ; O �` Crystal Bay, MN 55323-0066 Date reaeived: �� ! ��^� I y �,i,� � i•. ,,}� Slreef Addr�ess_ ; Received b : � �� r ,� � ; +,;'� G�F 2750 Kelley Paricway Plan review fee: �t %, y��"'w Orono,MN 55356 �eao�' ; Total Fee: ��5,3I� Main: 952-249�60Q Fax: 952-249-4616 I ww�v.ci.orono.mn.us �'his applicadon farm must be completed inlfull and all required inf�nnation must be submftted. Incomplete applkatio�s will be returned. {PJease print) Job Sit�e Address INATIOAI. , � S- � a Ih/rl�K- �7r-,'�Y c� Will this be a Parade of Homes,Remodelers Showcase-HIome or other Display Home? Yes No If yes,a speaa!event permit is required wfth Police Department en�Gty Councr7 approva160 days pnorfo bhe event ShutNe bus service wil!be required unless�p�icar+t demonsfrefes suffiaent onsite pa►fdng is aveilab/e. Non-pem►itted eventa wi/J not be ellowed. CONTRACTOR!AP L.ICANT lNF RMATION• /� � Name: rt�S �GN`� C�o�, �. S'tate Lic�nse# 93 '. � Expiration Date: Ze/2 Lead Certification Number. ^/ R- ° � Expiration Date: (�or werk on homes tirat were constructed prlor Eo f978; Phone: (,c!2- 7 Z3-- 3 ��ff�� Mailing Address: 3 o S v � � or3�l �� Z�P�� Contact Person: ,ti,,,� ,rtr.3 � � Applicant is: Carriractor ! Homeowner tciRaona� .�— Email andlor Fa�c -�� 3—�q � 77/D ' I I PROPERTY OWNER Ir{FPRMA7lON• ; Name: E-f f�L ti-� � Phone(daY): (,/Z -�?�?3�7 G,7 Address: � 7� L,q.i _�.ys � �1i•- City: t9/Lo-N a ZIP: Emaii andlor Fax � � � � PROJECT INFORMATION: I I Type of Project � Any esrth movement may require � MCWD review 8 permJts: ❑Door(s) ❑Remodel ❑Fire Dami ge Minnehaha Creek Wa3ershed District(MCWD) ❑Re ,asphalt ❑R�air ❑Stor►n Damage 16202 Minnetonka Blvd ! I Deephaven, MN 55391 Re-roof,cedar ❑Restoration ❑Wate Damage phone: 952-071-0590 ❑ Re�oof,other(specityl ❑Siding ❑Oth� (s i cifY) Fax: 952-471-0682 ❑Window(s) �•minnehahacreek.ora averall Pro'ect Description: ��- � Estimated Construation Valuation of Pro'ect( I i �land $ Z • Z APPLICANT ACKNOWLEDGEMENT: I . Agrees to provide all information r�equired or reques by the Building�epartment; • Certifies that the information supplied is true and c ct b the best of his/her kn�wledge. 'fhe appGcant recognizes that they are solely responsible for submitang a complete a� li tion being aware that upon failure to do so,the staff has no altemativve but to reject it until it is complete; • Some or all of the inlormation that you are ask provide on this appWcation is claasified by Siste law as either private or confidential. Private data is ininrtnation which ge r Ilylcannot i�e given to the pub{ic but can be given to the subjed of the date. Confidential data is information which gen y cannal be given to either the public or the subject of the data. Our purpose and intended use of this information is nually update our reconds and reco�ds of other governmental agenaes re uired b law. If ou re ta I the in(o ,the a licatlon ma not be issued. f ' ° 3 �t Onnlir�n4'e Cinn�h iro• ��•