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Gln 49012 09:06 Les Jones Roofing,Inc. fA>q 0017009 P.0011001 <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> windows, doors, siding, re-roof, etc.) <br /> O MaiIiPO am eg Permit number o?0�4"' —0 �o <br /> Q Q Crystal Say,MN 55323-0088 Date received: 2-//-/2- <br /> Street Address: Received by: <br /> 2750 Kelley Parkway Plan review <br /> Orono,MN 55366 <br /> Main: 952-249-4500 Fax: 952-2494818 wv►w.a.orano.mn.us Total Fee: a <br /> This application form must be completed in full and all required Information must be submitted. <br /> Incomplete applications will be retumed. (Please pont) <br /> GENERAL INFORMATION: <br /> Job Site Address: R QAn <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes El No <br /> ff yes,a spscW event pent*Is mquksd wink P+oft Department and Cly Cum*aWrovel 80 deys pdar to Nis event. Shuttte bue aerWce w9/be <br /> required w*u eppNhent denw8beArs sdffdant on4b pwft Is ava9ebfe. NorpefmNed events w9l not be aNbwed <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: 3 <br /> State License# (e 560 _ Expiration Date: <br /> Lead Certification Number. NAZI 40312-1 Expiration Date: 5 Z !S <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: 952- Sgl -11'2yl (office) qSA-16l-Atli Gr2—?37-i968(�19 <br /> Mailing Address: j ( W, zo MfibrF City: ZIP: <br /> Contact Person: Applicant is: (2!ptractor / Homeowner icnere one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: 8 4&A0AA C-AdU<- <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Pe ofProject: Any earth movement may require <br /> ❑Door(s) ❑Remodel ❑Fire Damage MCWD review&permits: <br /> Minnehahe Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt ❑Repair Storm Damage 16202 Minnetonka Blvd* <br /> Re-roof,id,)rr(8P6cIfy) ❑Restoration �COI Water Damage Desphaven,MN 55391 <br /> Phone: 962-471.0590 <br /> Re-roof, ❑Siding 13 Other(specify) Fax: 952-471-0882 <br /> F.p PkWindow(s) www.minnehahacreek.oro <br /> Overall Project Description: Rr14y E*#j) AEAr. G C OA& Room 4UA EPDM EtAr RdoFS ftmp yr o <br /> Estimated Constructlon Valuation of Project(excluding land) $ Z,7 ,50 507, AVPc.ac6 SOMI Hnnrp, <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 hielher 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 /> e 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 data Is Information which generally cannot be given to the public but can be given to the subject of the <br /> date. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information Is to annually update our records and records of other governmental agencies <br /> required by law. If-XLu refuse 12:9upply the information lication may not be Issued. <br /> Applicants Signature: Date: 7 /rLly <br /> i not i inrier.ot• nn.no.enl i <br />