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Fr�m:L�. JONES ROOFING 1 952 861 7009 09/13/2010 14:42 #362 P.002/002 <br /> City of Orono <br /> Building Permit Application for tnternal Work <br /> (windows, doors, sidtn , re-roof, etc.) <br /> O�O�O Ma1pP Bo Bx 6� Permit number. O/D�O <br /> Crystal Bey,MN 55323-0088 Date reoelved: � /� <br /> Street Addresa: Received by: <br /> � 2750 Kellay Paticway Plan review fee: <br /> 4 Orono.MN 55356 <br /> Total Fee: ���,p� <br /> Main: 952-248-4600 Fax: 952-249�4618 www.cl.orono.mn.us <br /> This application form must be completed in full and alf requlred inforrr�tion must be submitted. <br /> lncomplote applicetlons will be returned. (Plseae pnnf) <br /> C3ENERAL INFORMAT! N: <br /> Job Site Addres�: � (✓O �. � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes <br /> H yas e spec/e/evs�rt peimit ia r�qu/red wlOh Pollce Doperfinent and Clty Councl!approve/BD deys p►lor to fhe evorrt 5hutde bus servlcs U be <br /> requlrod unleas app/karrt demonatrafe�sulNdent on�park/n8!a avall8b/e. Non perm/Ked e►renta w1/l not be e/lowsd. <br /> CONTRACTOR/APP ICANT! ORMATION' <br /> Name: S �i Z�, <br /> State License# . Expiration Dete: <br /> Phone: 5a?- S -� o?� offlce cell <br /> Mailing Address: y'1 Ci : IP: �p <br /> Contact Person: c�.-- Applicant is: tractor meowner �cir�a on.> <br /> Emall and/or Fax: ` a' e ` " <br /> PROPERT'Y OWNER FqqMATION: /� �/ � � <br /> Name: �j'(u-i u/ltiw_ JL_��.�� <br /> Phone(day): � ,$' - <br /> Address: �•-- C :0/�-o ZIP: J 3� "// <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of ProJoct: My sarth movemerrt may roqufre <br /> , MCWD rvviwv d�peRnits <br /> ❑Door(s) ❑Remodel ❑Water Damage <br /> Mtn�ehahe Creek Waberahed District(MCWD) <br /> ❑Window(e) ❑Repair ❑Storm Damage , 18202 Minnetonka 8Nd <br /> Deephaven,MN 55391 <br /> ❑Siding ❑Restoretion ❑Other.(apecify) Phone: 982-471-0580 <br /> Fax: 852-471-0B82 <br /> "roof ❑Fire Da 8e www.minnehehacreek.org, <br /> overwit Pro ect uesen tion. 6 p � <br /> Est(mated Construction Valuation of Pro ect excludln land) 5 p <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Aprees to provida all i�ormation required or requested by the Butlding Depertment; <br /> • Certifles that the information supplied is true and correct to the best of hiaR�er knowledge. The applicarrt recognizes that they <br /> are solely responsible for submittinp a complete application being awere that upon failure to do so,�e staff hes no sltemative <br /> but to reject ft untll ft is complete; <br /> • Some or all of the fnft►rmatlon thet you are asked to provide on this appllcation Is daesifled by State lew es either private or <br /> wnfldentlal. Private data is infortnation which generally cennot be gNen to the publia but can be given to the subject of the <br /> data. Confiden�al data is infortnation whlch'generally cannot be given to either the public or the sub)eat of the date. Our <br /> purpose and Intended use of this infoRnatlon is to annually update our reoords and reoords of other govemmerrigl apenciea <br /> uired b law. If ou refuse to eu I th on the e Ifcetion me not be iaaued. <br /> ApPlicanYs Slgnature: w •• �J Date: q��.3 —l� <br /> Leat updated: 05-04-2008 <br />