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From:LES JONES ROOFING 1 952 661 7009 02/02/2012 14:41 #563 P.002/002 City of Orono Building Permit Application for Maintenance / Renovation Windows, doors, siding, re-roof, etc. Mailing Address: Permit number. O•�„O.�O PO Box 66 - Crystal Bay,MN 55323-0066 Date receMed: / StreetAddress: Received by: Kelley Park y Plan review fee: Orono, N Total Fee: Main: 952-249-4600 Fax: 952-2484616 yvww_cl.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Pisese print) GENERAL INFORMATIORL -T Job Site Address: !. �-•�ex_ Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? U Yes Uenim Byes,a special event permit is requked wNh Polkas Department and Gly Council approval 60 days prior to the event Shuffle bus wid be requbed unless appikwnt demonstrates sufflabN on-aNs paddng is available. /Yore-permuted evenfe will not be aAowied CONTRACTOR/APfP UCANT FORMA : Name- � P3 �?-c�S T� State License# (p-� d Expiration Date: Lead Certification Number. '-X iq? - V 03 7.2 -- I Expiration Date: •S_ /S (for work on hom that were constructedpr1l 1878 Phone: _ $J_ (office) (cell) Mailing Address: / (,dJ , Sis- C ZIP: Contact Perso �..� . Applicant Is: ntractor meowner (circle cael Email and/o Fax• 12 PROPERTY OWNER FO TION: Name: p Phone(day): Address: / Citys- ' ZIP: 5a3r JQ�' Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑Door(s) [3 Remodel ❑ MCWD review a Permits:Fire Damage Minnehahs Creek Watershed District(MCWD) ❑Re-roof,asphalt ❑Repair ❑Storm Damage 16202 Minnetonka Blvd f,cedar ❑Restoration ❑ Deephaven,MN 55391Water Damage Phone: 952-471-0590 ❑Re-roof,other(specify) ❑Siding ❑Other.(specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.or� Overall Project Descri tion: t'Qe !"P.w ez> 6rJ i Estimated Construction Valuation of Project(excluding land) S I /ao. DO APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognize&that they are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is Information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this inform annually update our records and records of other governmental agencies required by law. If You refu to setwtv th4f lnfbrmafbn.the application may not be issued. Applicants Signature: Date: Cg- Last updated: 08-09-2011 I