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�! <br /> ,� �,4l15l2014 14:27 Les Jones Roofing,inc. �A}��528817009 P.0011002 <br /> City ofi Orono #����� <br /> Bui�ding Permit Application for Maintenance / Replacemenfi / Renovation <br /> (No structural expansion. Only windows, doors, sidtng, re-roof, etc.) <br /> O Meiling Address: Permlt number: �O/ — �.� <br /> � �� PO Box 66 <br /> Crystal Bay, MN 55323-0086 Date received: �—1�P '/ <br /> Sfreef Address: Recelved by: <br /> �. �' 2750 Kell�y Parkway Plan review fee: <br /> �1�'� SNo�`�'G Orona, MN 55358 <br /> Total Fse� ��g � ' <br /> Maln: 9b2-2a9-Rt600 Fax: 952-Z49-4816 �vww.ci.orono,mn.us <br /> Thls applfcatfon form must be completed ln full and all required information must be submitted. <br /> Incomplete appllcatlons w(II be returned. (Please print) <br /> OE(VERAL INFORMATION: <br /> Job Site Address: /d� �7��,�G� �A,NS" <br /> WII)thts be a Parade of Homes, i�emodelers Showcase Home or other DlSplay Home? Yes No <br /> !f yas,e speclal event pennit!a requJred wlth Po!!ca Deperfment errd C7ty Cauncll epprovel 60 deys prior to the event. 5huttle bus servlce wlll be <br /> roqulred unless�ppllcenf damonst�ates suflklenf ornslle parking/s evellsble. fVan-permltted evenla wp(not be a!lowed. <br /> CONTRACTOR/APPLIGANT 1NFORMATION: <br /> Name: ��5 �'ou� Ro�'rnfG,i NG , ,.., „_ <br /> State Llcense# (�,�6p Expiration pate: 3/g� j/6 <br /> Lead Certification Number: N�Y" N3077—I Expiretian Date: ���g��,z- �_ <br /> (for work on homes the!were constructed prJor to 9978 <br /> Phona: (cell) �i�_ �,�?- ���� (ot�ce� q52- 8�i- z2wr <br /> MailingAdttress: Qy� ** gra Clty: ��,y ZIP: ,r���b <br /> Contact Person; GI�R�s �4No�'R g� Applicant is: ontractor I hlomeown�r �c,ra�o ono� <br /> Emall and/or Fax: �{,r�� � (� fcs �an�s ro o�'.�o, • [..avr� <br /> PROP�RTY OWN�I�IN�OI�MATION; <br /> Name: 5r�epH�N ��NES <br /> Phone (day): �j�Q� �!2� 4 SS�{ <br /> Address: City: ZIP; <br /> Email and/or Fax; <br /> pROJ�CT INFORMATION: Overall ro'ect dascri tion: � av� �piaca N� !� °� � <br /> Type of ProJect: Any earth movement may afso requlre <br /> ❑DoOr(s) ❑Remodel ❑Flre Demage MCWD revlew�permlts: <br /> Minnehaha Creek watershed District(MCWD) <br /> �Re-r0of,asphalt ❑Repalr ❑Storm Damage 18202 Minr►etonka Blvd <br /> [�Re-roof,cedar 0 Restoration ❑Water Damage Deephsvgn,MN 55391 <br /> Phone: 852�71-0590 <br /> ❑Re-roof,other(sp�clfy) �]Siding [f Other,(specify) Fax� 952-471-p8$2 <br /> ❑Wlndow(s) wv�w.minnehehecreek.or� <br /> Estlmated Gonstructlan Valuatlan of ProJect(�xcluding land) $, �fo. '7yS.00 „ <br /> APPLICANT ACKNOW�EDGEMENT: <br /> . Agrses to provlde all Informatlon requlred or requested by the Bullding Department; <br /> • Cert(Fies that the informetion supplied is true and correct to the best of his/her knowledpe. The applicant recognizes thet they are <br /> solely responsible for submltting 8 complst9 appllcatlon being aware that upon fallura to do so,the steff hes no alternat�vg but to <br /> reJect It untll it Is complete; <br /> • Some or alI of the Informatlon thet you are aeked to provlda on thfs appllcatfon ls claealflad by Stafe taw as elther prlvate or <br /> confidential. Private data is inform2tion which g6ne�&Ily C&nnot be$iven to the public but can b�given to the subject of the data. <br /> COnfldentlaf dat�ls Information whlch generelty cannot be glven to efther the public ar tha subjact af the data, Our purpoee and <br /> intended use of this information i�to annually update our records and reoords of other govemmantal agencias required by law, If <br /> ou refu9e to su I the Inf atlon th a Ilcatlon ma not ba ieaued. <br /> Applicant's Signature: �-� Date: ��l��/fF <br /> Owner's Signafiure: Date: <br /> Last Upd&ted:03/06/2013 <br />