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05l07l2013 11:07 Les Jones Roofing,Inc. �AH�528817009 P.001l002 <br /> � - Gity of Orono <br /> Bui�ding Permit Application for Maintenance / Renovation <br /> (wfndows, doors, sidtng, re-raof, etc.) �# 2k?� <br /> ( MeUing Address: <br /> Permit numbar: <br /> Q��,�0 PO Box 66 <br /> Crystal Bay,MN 55323-0088 Dete received: <br /> � � ShaetAddress: Fteceived by: <br /> 2750 i4eUey P�rkway Plan rgvfew f9e: <br /> �.� o�;O Orono,MN 5635B <br /> 7atal Fee: <br /> Main: 952-249-4600 Fax: 952-249-4618 w�n�w.cl.orono.mn.us <br /> This application farm must be completed fn full and ail requlred lnformatlon must be submltted. <br /> Incomplete appllcations wfll be returned. (Please print) <br /> OENERAL INFORMATION: <br /> Job Sfte Address: �� �L�� �2l V�� <br /> Wlll thls be a Parade of Homes,Remodelers 5howcase Home or other Display Home? Yes <br /> If yes,a apeclel evant parmlt!a roqulrod wlth PolJce Deparfinent and Clty Ceuncl!epprrave/60 dAys prlor to the event. Shunle bua servfce wl11 De <br /> roqulred unlesa applKant demonatrates sufNclent orwatte psrking!a ava/lable. Non parmfKed events wf�not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: L�4 5c,nt�s RaoFi r� t <br /> State License# �jC pp�,5(PD _ __ _ _ __ _ _ ExpiraEion Date: 3I�� f 11J, <br /> Lead Cettlflcatlon Number: NA�Tw S10372 —1 Expiration Date: s'f 2p��,�-� � <br /> {for work on homea fhat we�e constructed prlor to 9978 <br /> phon�: �'1 $2� �l�?T2�l7 (offic�) ��2- Z37— �968 (cell) <br /> Mailing Address: ��{� �/, gp� �Y-��� City: , „/ �Ip: �� <br /> ConE�ct PerSon: GµQ,�5 ,�N D�San{ Applicant is: o / Homeowner �Clrolo one) <br /> �mail andJor Fax: Ch r rg a. � ��s Sdncs �'od�cna. e.crn <br /> �ROPERTY OWNER INFORMATION: <br /> Name: (R l,.Jin) �/bCopS <br /> Phone (day): ���,.. ��'�� J�pQ <br /> Address: Clty: ZIP: <br /> Emafl and/or Fax <br /> PRQJEC7 INFORMA710N: <br /> lype oi ProJect: Any earth movement may require <br /> �poor(s} � Remodel ❑Fire Damage MCWD revlew&permlts: <br /> Minnehaha Creek W�tershed aistrict(MCWD) <br /> p R�rooF,asphalt ❑Repair ❑ Storm Damege 18202 Mlnnetonka Blvd <br /> e roof,cedar ❑Restoratlon ❑Water Damege peeph2ven,MN 55391 <br /> Phone: 952-471-0590 <br /> 0 Re-roof,other(spacfry) 0 Sidirtg ❑Other.(apeGfy) �ax: 852-471-U682 <br /> ❑Window(s) www.minnehahacresk.ora <br /> Overall ProjectDescriptian: /2�sMm ��-�NGL� ,4�» R�F'c-�r� w�r� C �� <br /> Estlmated Constructfon Valuation of Project(excludfng land) $ "7�, dQOg <br /> APP�,lCANT ACKNOWLED4�MENT: <br /> • Agrees to provlde alI Informetlon rsquired or requested by tf�e Bullding Deperiment; <br /> . Certifies that the information supplied is true and correct to the best of his/her knowledge. The appllcent recognlaes thet they <br /> �re splely responstble for 9ubmftting a complete appllcatipn being awara thai upon failure to do so,the Staff has no altemative <br /> but ta reject It untll it is complete; <br /> . Some or all of the fnformatlon thet you are asked to provlde on thla appllcatlan Is cl8ssifled by State law as elther priv�te Or <br /> confrdential. Priva�e data fs inforrnati0n which generally cannot be giVen to the public but can be given to the subj�ct of the <br /> � dete. Confldentlal dete fa informatlon whlch generel[y cannot b0 given to elthar the publlc or the subfect of the dsta. QUr <br /> purpose �nd intended use of this information is to annually update our record� and recorda of other government�l agenGleS <br /> re ulred b lew. If ou refuse to su the fnlorm�don the e IfcaUon m� no#ba issued. <br /> ApplicanYs Slgnature: Date: �/ 7��� <br /> G.ae�Updatea: aB-Og-ao�� <br /> Ge��us �,u�� T <br />