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09/10/2012 12:55 Les Jones Roofing, Inc. (F A)()9528817009 P.001/002 <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> C°� Cr Box 8B <br /> `" �� Crystal Bay, MN 55323-0066 Date received: <br /> 0,b O Street Address: Received by: <br /> 14, ')i 1J��?% `� 2750 KelleyParkway <br /> t vi o„ Plan review fee: <br /> Orono, MN 55358 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4818 wvinttsi.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: / 2.6 0 W 004#1-14- Ave <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes ❑ No <br /> If yea,a special event permit Is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: LIES SONE5 RaoFrm.►4. IN c• <br /> State License# (,s(D p a Expiration Date: 3/3/f t 3, <br /> Lead Certification Number: Nor- goal 2-I Expiration Date: Clair/ t r <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: 9 s 2- S 91- 25'17 (office) 4,/2- 237- /944 (cell) <br /> Mailing Address: 9 y ' W, gel" smer City: Otoo,orr v ran/ ZIP: 53-y2_0 <br /> Contact Person: CsFR.rs r4NDoe s sty Applicant is: ontrac / Homeowner (circle one) <br /> Email and/or Fax: 4rr s G1, Ly k y i es roo1i r - corn <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door(s) 0 Remodel 0 Fire Damage MCWD review permits: <br /> Mlnnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Xs-roof, cedar 0 Restoration LI Water Water Damage ven,MN 55391 <br /> /� Phone: 952-471-0690 <br /> ❑Re-roof,other(specify) ❑ Siding ❑Other:(specify) Fax: 952-471-0882 <br /> www,minnehahacreek,ora <br /> 0 1Mndow(s) <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ (o q} $o0 -- <br /> APPLICANT <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 hislher 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 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 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 you refuse to supply the information,the application may not be issued. <br /> Applicant's Signature: Date: 9//o//Z <br /> Last Updated: 08-09-2011 <br />