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� From�LES JONES ROOFING 1 952 881 7009 09/07/2011 13:13 #205 P.002/002 City of Orono . Building Permit Application for Maintenance / Renovation (windows� doors, sidin , re-roof, etc. Mai/ing Address: Pefmit number: a D �j O.��,�0 PO Box 86 Crystal Bay, MN 55323-0066 Date reoeived: o. Street Address: Reoeived by: ��" 275Q Kelley Parkway Plan revieW fe ��SSo¢4� Orono, MN 55358 Total Fes: p5 ,37 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 e submitted. Incomplete app[ications will be returned. (P/ease print) GENERAL INFORMATION: .— � Job Slte Address: ,3 O y`� ,��`��P�� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes PI yes, a specia/event permR ls iequJn9d with Police Deparfinent and Ciry Council approval 60 days p�or to the event. Shuttle 6us service w1116e iequlred unless appllcant demonstrates suAScient on�ite peAUny!s avelleble. Non-parmi(ted ev�ents w!!/not be allowed. CONTRACTOR/APPLICANT INFORMATI . Name: �� 1� . State License# Expiration Date: Lead Certification Number. � �—_ � � _ � Expiration Date: ,5`��_ �s (for work on homes that wero construcfed pr/or to 1978 Phone: �S'� _ $$/- a�'�y/ (office) (cell) Mailing Address: l (� , 'f�- �-c . Ciry: o - IP: 5 Contact Person_ ` Applicant is: ntract / H eowner �ci�ie o�•� Email and/or ax: --� _ $ PROPERTY OWN NFORMATION: Name: p ��j r�a_�- o Phone(day): Address: .3 o g9 c'-�-rv�'2 cJ ��-�--p City: Q/'6�j ZIP: ,S3'35'� Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movemont may roqulre ❑Door(s) ❑ Remodel ❑Fire Damage MCWD review�permits: Minnehaha Creek Watershed District(MCWD) ❑Re-roof,asphalt ❑Repair ❑StoRn Damage 18202 Minnetonka Blvd Deephaven, MN 55391 roof,cedar ❑Restoration ❑Water Damage Phone; 952-471-0590 ❑Re-root,other(spoclfy) ❑ Siding ❑Other:(specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.ora Overall Pro'ect Descri tion. ct�- Q � ��6 p Estimated Construction Valuation of Project(excluding land) $ APPLICANT ACKNOWLEDGEMENT: ' • Agrees to provide all information r�quired or requested by the Building Departrnent; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responslble for suhmitting a complete application being aware that upon failure to do so, the staff has no altemative but to reject it until it is complete; • Some or all of the information that you are asked to provide on fhis 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 date is information which generally cannot be given to either the public or the subJect of the data. Our purpose and intended use of thi information is nnually update our records and records of other governmental agencies re uired b faw. !f ou refuse t u e inf atio the a lication ma not be issued. Applicant's Signature- Date: -7 — � — � � 1.est Updeted: 08-09-2011 •