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1111212013 11:23 Les Jones Roofing,Inc. (FAY)9528817009 P.002/002 14(-2-4-19,56. City of Orono Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) A r Mailing Address: PO Box 68 Permit number: ION 0 jV Crystal Bay, MN 55323-0066 Date received: Street Address: Received by: 2750 Kelley Parkway Plan review fee: �R6SH0�4 Orono,MN 55356 Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www,ci.orono.mn,us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: 3SS" rEay.420 Will this be a Parade of Homes, Remodelors Showcase Home or other Display Home? ❑Yes ❑No If yes,a special event permit Is required with Police Department end City Council approval Bo days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: �. �5 3;rvES /E0oFi4/6` /nuc. . State License# Expiration Date: 3/3111,4 Lead Certification Number: NAT_tko 2, l Expiration Date: 5.-/Z?/ t g— (for work on homes that were constructed prior to 1978 Phone: (cell)(Pty,- 2,37- (PS' (office) q,2.-7(7- 22/ Mailing Address: qt q( fo Sr/Le-&---r" City:Strobru cnyafon! ZIP: 5-542-4o Contact Person: C,efp.s AN 14 Applicant is: I<'n71 / Homeowner (circle one) Email and/or Fax: c{+r15 � doh p� Gawp PROPERTY OWNER INFORMATION: Name: Mc.an,2 ! d-S-cp 62u c.6- Phone (day): _ Address: 5^yv4e *3ou City: ZIP: Email and/or Fax: PROJECT INFORMATION: Overall project descrjption: Type of Project: Any earth movement may also require ❑Door(s) ❑ Remodel ElFire Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) El Re-roof,asphalt ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd ARe-roof, cedar ❑ Restoration LI Water Damage Deephaven, MN 55391 Re-roof, other(specify) 0Siding ElOther:(specify) Phone: 962-471-0690 Fax: 952-471-0682 ❑Wiindow(s) www.minnehahacreek,orq Estimated Construction Valuation of Project(excluding land) $ --)9) aoo APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all Information required or requested by the Building Department; • Certifies that the Information supplied Is true end correct to the best of his/her knowledge. The applicant recognizes 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 information Is to annually update our records and records of other governmental agencies required by law. If you refuse to supply the rmation,the application may not be issued. Applicant's Signature: • � Date: t r l(.21/2 Owner's Signature: Date: Last Updated;03108/2013