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�r�m�5 JONES ROOFING 1 952 661 7009 09/19/2011 13:53 #243 P.002/002 <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> windows� doora, sidin , re-roof, etc. <br /> O���O MailiPO 8ox 86� Perm�t number: d0 _ <br /> Cryet81 Bay, MN 55323-0086 Date roeeived: <br /> Sfreet Address: ' R�"�bY <br /> � � 2750 Kelley Parkwsy Plen revfew tee: <br /> Orono,MN 58358 <br /> Total Fee: C� <br /> Main: 952-248-4800 Fax: 952-249-4618 �vww.ci.orono.mn.us ���vv <br /> This application foRn must be completed in full and all requirod informetion must be submitted. <br /> Incomplste appllcatlons will be roturnod. (P/ease prin� <br /> GENERAL INFORMATION: <br /> Job Sito Addrass: ��C�(v GJt3r�cQ <br /> WIII thb be a Pando of Homa�, Romodelers owcase Home o�othe�Display Home? Yes <br /> N y�e apecl9/s�s►rt Po►m�Is�s9u�sd wl�h Polk;s Deparlmant and C!!y Courx�approvel 80 dsya p�Or to Ehs evdr� Shu(ds bus teMae wIN bs <br /> I�rqu/red uMeas appllceM dsmonabotBa suflh�ent on�,aKs perldnp/a evd/abb. Non-penniltrd svsMs w�/not be aA'owsd. <br /> CONTRACTOR/A PUCAN�FORMA <br /> Name: �5 G�.�� Z,L� . <br /> State License# Expiretbn Dete: 3-3/ _/y_ <br /> Leed Certiflcetion Number_ �j�-T. .c���7a _/ E�Praticn Date: -�$../s <br /> (fbr work on hom tliat were conatructed piioi tn 1878 <br /> Phone: � � $g/- � a (office) (cell) <br /> Mailing Addrass: � �F�c- Cgy; (p: <br /> Contact Perso • ` Applicant ia: ontractor / meowner �c��ei.on.� <br /> Email and/or ax: �-j _ <br /> PROPERTY OWNER INFORMATION� <br /> Name: ��.G�� �- �N ri i //� �L-�•L,� <br /> Phone(day): l�- r7a p- �•y0 <br /> Address: a`�� �Co �_�a�-wdo � ��Y��/`�-O ZIP: S`� �''� <br /> Email�nd/or Fax —" <br /> PROJECT INFORMATION: <br /> ryps of ProJ•c� Arry�arth mowma�may require <br /> ❑Door(s) ❑Remodel ❑Fire Damaoe MC���&pertnits: <br /> Minnehaha Creelc Wat�rehed District(MCWD) <br /> ❑Re-roof,asPhalt ❑Repair ❑Storm Damage 18202 Minnetonka Bivd <br /> �roof,codar ❑Restoration ❑Water Damage �phaven,MN 55391 <br /> Phone: 952-471-0690 <br /> �e-�oof,oth}t(sp�eay) ❑Siding ❑Other.(spedfy) Fax: 852�71-0682 <br /> �v� Y'1l.� /' �}1Mndow(e) www•minnehahacreek.orn <br /> Overali Pro ect Descri o : �u..�- a� ,F- /'�/`-a7�� L�1, ,pa., <br /> Eattmated Constnictlon Valuatlon ot Pro ect excludin land $ ' ,3 . <br /> �a�►- o�L�G ..G /'P� c�-�t.-z-s� � - <br /> APPLICANT ACKNOWLEDOEMENT: <br /> • Agreea to provlde all iniormatlon roquired or requested by the Bu{Iding Depertment <br /> • Certtfles tl�et the Enformation aupplied is true end cort�e�t to the best of hidher knowledge. The applicant reoognizes that they <br /> aro solely reaponaible for aubmitting a canplste application being aware thst upon fallu�to do so,the stefi has no altemetive <br /> but tv rejvd it urrtll R is complete; <br /> • Soma or all of the information that you are�ked to provide on thls applloatlon Is clesslfled by Stete lew as either private or <br /> cor�fldeMial. Prlvate date le Informatlon which generelly cannot be pNen to tha public but can be oiven to 1he subjed of the <br /> data. ConfiderHial deta is infortnation whieh generslly csnnot be eiven to either the pubGc or the subJect af the deta. Our <br /> purpo�e and irrtended use of this f RnaUon Is to annually updete ou� records end recorda of othar govemmerrtsl egendes <br /> uired b law. If ou refuse the i o Ms lication me not be iaaued. <br /> ApplicanYs Signature: Date: 1 �q�-/� <br /> �as�updaoad: oe-oe-zo�� <br />