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� 09l0212014 13:17 Les Jones Roofing,Inc. �A��528817009 P.002t002 <br /> , . . <br /> ��s�a,� C�ty of t�rano <br /> Building Permit Application for IUlalntenance / Replacement/ Renovatlon <br /> (No structural expansion. Only windows, daors, siding, re»roof, etc.) <br /> ' Malling Address: permlt numb6r; <br /> �01�T� P4 gox 88 - <br /> CrystaE Bey,MN 65323-0066 Dete recelved: q-3-/ <br /> Stre9t Addr6Ss: Received by: <br /> y`�t �� Orono,MN 55356 Y Plan review fee: <br /> ''k SKo�-�' ,ro�i F�: � �(g,�$ <br /> Meln: 952-249-R600 Fax: 952-248-4616 vwvw.ci.orono.mn.us <br /> 1"his application form must be completed in full and all requlred Inform�tldn must be submitted. <br /> Incomplete applications wlll be returned. (P/ease print} <br /> �ENEFiAL IN�ORMATION: <br /> Job 31ts Address: / S#O,QEZI Dl�l <br /> WIII this be a Parade of Homes,Remodelers Sh�wcase Home or other Dlsplay Home? Yes No <br /> If yee�e apecee!event perm�Is ropulrod wlth Rolka Department enar City Cowu�epprova!ep deya prlor M the evsru Shuttle bua serv/ce w�l be <br /> requlreed uMess appNcarN demanatratas aufRdent oo-sita pa�ldng/s evalbb�s_ Non-pannitted evanta wll!not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: ��S <br /> Stete License# f���p Expiration Date: 3/3 i�/� <br /> Lead Certification Number: ,��-__yp 3-��_� Explratfon Date: _s-�ap��s- � <br /> (for work on homes that were constructed pHor to 7878 � �— <br /> Phone: (cell) (�1,�����t �q/p g (o��) �Se?- 7G 7- d7 S/7 <br /> Malling Address: 9yr W- '�S &r ��tY- �3cc�r��v�;-zv✓ Z�P� S'sy�d <br /> Contact Person: y�rS �4�ro�72suN Appllcant is: on raa or / Homeowner (Grclo Ono) <br /> �maiE and/or Fax: � o� . 4 <br /> PROp�R'1'Y OWN�R IIVFORMATION: <br /> Name: I,21rJ�a! ,T�ea/3S <br /> Phone(day)� �I�•�,/9.. 7 a a� <br /> Address: City: ZIP: <br /> Em�il�nd/or Fax <br /> PROJECT INFORMATION: Overall ro'sct descri tlon: <br /> 7ype of Projec�: Any earth movement may alsp requl�e <br /> ❑D��(s) ❑Remodel ❑Fire Damege �C�p��ew&permlts: <br /> Re-roof,asph�lt ❑Repair ❑Storm Damage Mi�nehaha Creek Wat�rshed Distr�t(MCWD) <br /> ❑Raraof,cedar ❑Restoratlon ❑WBter Damage D ephav`en,�MNk55391 <br /> ❑Re-roof,other(9poclfy) ❑Stding ❑Othor.(spocify) Phone: 9b2-471-0590 <br /> Fex: 952-471-0882 <br /> ❑Windaw(s) www.minnehahecdsek.or,� <br /> Esttmated Constru�t(on Valuation of ProJect(excluding land) $ !7�, S�O• - <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agre�s to provlde ell InformaHon required or requested by the Bullding Depertment; <br /> • Ce�tifies that the Informatlon suppUed Is truQ and o0rrecc:t to the�st of his/her knowladge. The appllcerrt recognizes that they are <br /> solely responslble for submitfing a completa eppllcaHon being awsre that uppn failure to do so,the s#aff has no eRemaUve but to <br /> �ect it until it le c�mplete; <br /> . Some or all of the Informabon that you are asked to provide on thls appI�8U0n IS dassified by State law as either pm�ate or <br /> con�ide�tial. Private data ie informaUon whlch generally Cannot be�iven to the public but c�n be glven to the subjed of tY�e data. <br /> Confider�Usl date Is Inipmrta6on which generally cannot be given to efther the publiC or thA subject of the data. Our purpose end <br /> inte�ded use of this i�torm on is to annustly update our records and records of other governmer�tal agencles required by law. If <br /> ou refuse to Su th ' atlo e a Ilcstlon ma not be Igsued. <br /> Applicant's Signature: � Dete: `����/�{ <br /> Ownar's Sig�ature: Date: <br /> Last Updeted:03/06/2013 <br />