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From:LES JONES ROOFING 1 952 881 7009 08/30/2011 13:56 #179 P.002/002 <br /> J . <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number. <br /> Og,O,�O PO Box 66 <br /> Crystal Bay,MN 55323-0065 Date received: <br /> Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> *-4�P Orono,MN 55356 <br /> Total Fee: <br /> Main: 952-2494600 Fax: 962-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> GENERAL INFORMATIO Incomplete application III be returned. (Please print) <br /> Job Site Address: oZ tom. <br /> Will this be a Parade of Homes,Remodelem Showcase Home or other Display Home? Li Yes <br /> Hyea;a spedel event panni t Is required wlOb Pollm Department and City Council approval 60 days prorto the event Shuttle bus ,vice wNbe <br /> requited unNss applicant demons&wOs suffkient on-sits pardng is evailabis. Non pennlod evenb wpl not bo allowed. <br /> CONTRACTOR/qP PLICAUfJ NFORN9�1N: 11 <br /> Name: "-:5; 1J07t.e 7.07Z•(-7 �V� --r . <br /> State License# (e�f�p Expiration Date: <br /> Lead Certification Number. ''h Q T A,4.o3-►,,? _/ Expiration Date: <br /> (for wort on homes t91 were consbucted prior to 1978 <br /> Phone: -6�_ $ �� (office) (cell) <br /> Mailing Address: City: P; <br /> Contact Person „`, Applicant is: ontractor eowner (ona.one) <br /> Email <br /> PROPERTY OWNErRJNFO 104 <br /> Name: �y <br /> Phone(day): <br /> Address:_ �, �. ,� City , ZIP: S5 35�, <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door(s) ❑Remodel ❑Fire Damage MCWD review 3 permits: <br /> Mlnnehaha Creek Watershed District <br /> (MCWD) <br /> 13 Re-roof,as haR ❑Repair <br /> ❑Storm Damage 15202 Minnetonka Blvd <br /> e-roof,cedar ❑ Restoration ❑ Deephaven,MN 55391Water Damage Phone: 952.471-0590 <br /> ❑Re-roof,other(specty) ❑Siding ❑Other.(specify) Fax: 952-471-NO2 <br /> ❑Wlndow(s) www.minnehahacreek.oro <br /> Overall Project:Description: p,� .L <br /> Estimated Construction Valuation of Project(excluding land) $ ,'3 e94 5 (o- c r•- <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied Is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative <br /> but to 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 Stats law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the dela. Our <br /> purpose and intended use of this informagao is to annually update our records and records of other govemmental agencies <br /> required by law. If you refuelli Wsupolvini'dimation,the application may not be issued. <br /> Applicant's Signature: Date: <br /> Last Updated: 08-09-2011 <br />