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+ e7/16!2013 13:30 Les Jones Roofing,Inc. fW)52M170 P.0021002 <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. only windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number aV +490 <br /> PO Box 86 <br /> Crystal Bay,MN 55323-0066 pate received: 7—) b-t3 <br /> Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> `�ttK SHo��G Orono,MN 55358 <br /> Total Fee: Ll 0. <br /> Main: 852-248-4800 Fox, 962-2494816 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: MA WA ROAP <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes No <br /> Nyes,a special event pem*/s requprd with Police Department and Co Council approval 60 days prior to the event Shuttle bus servk a w1N be <br /> ragtdrsd unbar applk ant demonstrates sur►gc/ent on-site parking Is avexable, Nw9emdtled events w9t not be Mowed, <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: p <br /> State License# (4560 Expiration Date: 3 3r <br /> Lead Certification Number: Nq-T 40372-1 Expiration Date: �� g f /�^ <br /> (for work on homes that were consfrucfed prior to 1978 <br /> Phone: (cell} & 7. - 231- L C(o$ (office) q S,t- 7 111 <br /> Mailing Address; k( 8pvk S City: zip: rf- 20 <br /> Contact Person: Applicant is: &�/ Homeowner (creone) <br /> Email and/or Fax: ca <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJI=CT INFORMATION, Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑Door(s) ❑Remodel ❑Fire Damage MCWD review&permits: <br /> ❑Re-roof,asphalt [I Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> []Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 <br /> �Re-roof,other(specity) ❑Siding []Other.(specify) Phone: 952471-0590 <br /> Fax: 952471-0682 <br /> 2 LCPOM F'la4"r ❑Window(s) www.minnehahacreek.om <br /> Estimated Construction Valuation of Project(excluding land) $ l°It my— <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agrees to provide all Information required or requested by the Building Department,- <br /> Certifies <br /> epartment;Certifies that the Information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a Complete application being aware that upon failure to do so,the staff has no alternative but to <br /> reject it until It Is complete, <br /> • Some or all of the Information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private date Is Information which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data Is infarmaDI�StD <br /> generally cannot be given to either the public or the subject of the data. Our purpose and <br /> Intended use of this Info tionnnuallyupdate our records and records of other governmental agencies required by law. If <br /> ou refuse to su I Informaea lostion mg not be Issued. <br /> Applicant's Signature: Date: <br /> Owner's Signature: Date: <br /> last Updated:03IM013 7-7 t ,?� <br />