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From:LES JONES ROOFING 1 952 881 7009 04/28/2011 10:39 #889 P.002�002 <br /> If f <br /> City of Orono <br /> Building in9 Permit Application for Internal Work <br /> u <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number. oW -a <br /> O•¢.0,j�O PO Box 68 .411015-11 <br /> Crystal Bay,MN 55323-0066 Date received: <br /> StreetAddress: Received by.- <br /> 2750 <br /> y:2750 Kelley Parkway Plan review fee: <br /> g� Orono,MN 55358 �y p <br /> Main: 952-249-4600 Fax: 952-2494616 www.ci.orono.mn.us Total Fee. (,, <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: qX5 <br /> Will this be a Parade of Homes,Remodelem Showcase Home or other Display Home? 0 Yes o <br /> fr yes,a special event permit is required with Pollee Department and Clay Council approval 60 days prior to fire event Shu(tfe bus d6rvke wAl be <br /> required unless applAcent demonsdates suffAcknt on-sft parking is available. NonpemdHed events wff not be a/lawd. <br /> CONTRACTOR/AP UCANT RMATIO <br /> Name: e—A— S JLrTb i 1- --�-- . <br /> State License# Expiration Date: 'i <br /> Lead Certification Number. '71 Q _ �/, 0,3 7,y _ Expiration Date: <br /> (fbr work on homes OW were com r&u~prior to 1878 <br /> Phone: c7 ;2 (office) ( II) <br /> Mailing Address: City: ZIP: S <br /> Contact Person: a. Applicant is: ntmctor / &meowner tciroi. <br /> Email and/or Fax - 6 6E Gd-rx--- <br /> PROPERTY OWNrNFORMATION: <br /> Name: " <br /> Phone(day): & _ _IV Z39 <br /> Address: 8'S d x a�.�rL City: Q�� .o ZIP: ,$`S'.3�S` <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> [IDoor(a) ❑Remodel [3 Water review S permits:Watar Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Siding ❑Restoration ❑Other.(specify) Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> of ❑ Fire Damage Fax 952471-0682 <br /> www.m innehahacxeek.ora <br /> Overall Project Description: -C.r� p e. <br /> Estimated Construction Valuation of Project(excluding land) $ /19.1? Od <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 Jthat 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 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 /> data. Confidential data is information which generally cannot be given to either the public or the subject of the d . Our <br /> purpose and intended use of this Informaliong.A to annually update our records and records of other governmental agencies <br /> required by law. If you refuse !*Ply the bftrmaftq,the application may not be Issued. p <br /> Applicant's Signature: Date: <br /> Last Updated: 03-01-2011 <br />