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From;LES JONES ROOFING 1 952 681 7009 08/19/2010 14:37 #262 P.002/002 1 City of Orono ' Building Permit Application for' Internal Work (windows, doors, siding, re-roof, etc. Malling Address: Permit number: O'�.+O.�O PO Box 66 Crystal Bay, MN 55323-008B Date received: � a StreetAddress: Reoeived by: ��' 2750 Kelfey Parkway Plan review fee: ��o�'� Orono. MN 55356 Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This appltcation form must be completed in full and all required information must be submifted. Incomplete applicatlons will be returned. (Please print) GENERAL INFORMATION: ��, � � Job Site Address: / ��-r�> �a �. 1?r--� V�. Wlll this be a Parade of Homes, Remodelers owcase Home or other Display Home? Yes o l/yes,a special event permit is requlred wfU�Police Departmvnt and Clry Councll approva/60 days pr/or to the event. Shutt/a bus servfce ll be required unless applicant demonstrates su�ciont on,s/te parking fs evailab/e. Non-perm/fted events Will not be allowed. CONTRACTOR/AP LICANT ORMA � Name: ' � ;J.-�c�c:1 . ' State License# Expiration Date: � ._� _ �� Phone: 5' _ — office cell Mailing Address: � , �!-� Ci : t IP:�� S� �� Contact Person: ` Applicant ls: ontractor / meowner �ci.�ie ono� Email and/or Fex: �,y�y PROPERTY OWN,ER�NFORMATIO� Name: `�I cc-�.P..�,r �-c,,P Phone(day): n'��_ ,�.�i� — ,��e d� j Address �// C'�L, ,,�c,, (i�i � �� . Cpty�Gz.�2� ZfP' SS 3 cJ/ � Email and/or Fax CJ PROJECT INPORMATION: Type vf Project: My earth movement may require ❑Door(s) ❑Remodel MCWD revlew 8 permits ❑Water Damage ❑Wlndow s Minnehaha Creek Watershed District(MCWD) ( ) ❑Repair ❑Storm Qamage 18202 Mlnnetonka Blvd ❑Slding ❑Restoretion Deephaven,MN 55391 ❑Other. (specify) Phone: 952-471-0590 Fax: 952-471-0682 Re-roof ❑Flre Darrlage www.minnehahacreek vrq Overall Projeet Description: �h �� _ Estimated Construction Valustion of Proj (excluding land) $ �� d� APPLICAN7 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 recognizes that they are solely responsible for submltting a complete application being aware that upon failure to do so, the etat�has no elternetive but to reject it until it is complete; • Some or all of the information that you are asked to provide on thls appUcatlan is classified by State law as either private or confldential. P�vate data is information which generally cannot be given to the pu6lic but can be glven to the subject of the data. Confidential data is information which generally pnnot be given to either the public or the subject of the date. Our purpose and intended use of this information is to annually update our records and records of othar governmental agencies re ulred b law. If ou refuse to su I the information,the a lication ma not be issued. ApplicanYs Signature� �,�� —l — �� Date: � Last Updated: 05-04-2009 t ��i � � � , i, �;