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09/1712015 15:10 Les Jones Roofing, Inc. �W(�528817009 P.002l003 <br /> ���,�o City of Orono <br /> B�i[ding Permit Application for Maintenance / Replacemen# I Remodel <br /> (i.e. windows, doors, sidin , re-roof, etc. — NO STRUCTURAL EXPANSION) <br /> Mailing Rddress; Permit number: � `"� � �vl 2 � <br /> ��� PO 8ox 66 <br /> � Crystel Bay,MN 55323-0068 Dafe received: � ���"� I <br /> Street Address; Receiv9d by: ��� <br /> � �' 2750 Kelle Parkwa � � <br /> z Y Y Plan revfew fee: <br /> ��q� s�o��"G~ arana, MN 5S35fi <br /> Total Fee: .(� � <br /> Mafn: 952-249-4800 Fax; 952-249-4616 w�nn+.ci.o[ono.mn us '�"t <br /> This application form must be campEeted In full and al[requlred inform�tion must be submitted. <br /> Incomplete appllcatlons wlll be returned. (Please pnntJ <br /> GENERAL 1NFORMATIOW: <br /> Job 8ite Address: 1 � �p(] �.�(��f'�q..�� L,��rE <br /> Will this be a Parade of Homes, Remodelers 5howcase Flome or other dlsplay Hame? Yss No <br /> /f yes,G 9peCidl event pemfit!s n9qulrt9d Wlth PoI(Ce Dep&Mment 9nd CIly Councll Approva160 days prlor to fhe event Shuftle bus serviCe wil!be <br /> requll�d un/e99 dpplfCant demOtlstl'&te9 SulffClent On��e parldng!s avallatrle. Non-pennitfed events wll!not be ellowed. <br /> CQNTRACTOR!APP�ICANT INFORM�ION: <br /> Name: IL�S Tvr.��5 a�.�at•��n+�. <br /> State License# (os'�p Expiration Date: �l�,��� <br /> Lead Certification Number: N�.-�,c}pg-��.�, Expiratfon Date: S gg �� <br /> (fnr work on homes that were constructed prlor to J978 <br /> Phone: (cell) (p�Z• 2g7• ( (�� (office) � �$I• y�,y� <br /> Mailing Address: �' City: ZiP: <br /> Contact Person; C�� �Kp�,y� Applicant is; ontractor / Homeowner �c�.c�.ono� <br /> Email and/or Fax: Ghr�sO.. �s�pr►cs ro v� , Co 9S� � 8�'/- ?uv�I <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��,�4�H /�/c�rtfUAl _ <br /> Phone(day): (v!Z. SL(a• lO�� <br /> Add ress: City: Z!P: <br /> Email and/or Fax: <br /> PROJECT INFORMATtON: 4verall ro�ect descri tion: <br /> Type of Project: Any earth movement may also requirs <br /> ❑ aor(s) � (]Remodel ❑Fire Damage <br /> ,MCWD revlew 8�permlta: <br /> �e-roof,asphalt ❑Repalr ❑Storm Damage Niinnehaha Creek Wate�shed District(MCWD) <br /> /�� 18202 Mlnnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration ❑Watsr Damage Deephaven,MN 55391 <br /> ❑Re-roof,other(epeclfy) [�Slding ❑Other. (specify) Phone: 952-471-0590 <br /> Fax; 952�71-0682 <br /> �Wlndow(s) www.minnehahacreek.ora <br /> Estimatsd Constructlon Valuatlon of ProJect(excluding iand) $� OQ. o O <br /> APPLICAN7 ACKNOWLEDGEMENT: �� �. � T. '�'z'� � <br /> . Agrees to provlde all Informatfon requlred or requested by the Building Department; <br /> . CeRlFles that the Informatlon supplled is true and correct to the best of his/her knovv�edge. The�ppllcent recognlzea that they are <br /> solefy responsible for subrnitting a complete application b9ing�ware that upon fallure to do so,th�staff has no alternative but to <br /> reJect lt untll lt is complete; <br /> . Some or atl of the lnformatlon that you are asked to provide on this application is Clasalfled by Stats )ew as either private or <br /> conAdential, Private data is informatia�which generally cannot b9 glvgn to the pubBc but cen be given to the subject of the data. <br /> Confidential data is information which generally cannat be gfven to elther the public of the subject of the dat9. Our purpose and <br /> Intended use of this inFormation is to annually update our record8&nd reCords of Oth�r governmental egencies required by law. 1f <br /> ou refuse to su I the ation the a lication ma not be Issued. <br /> Applicant's Signature: r Date: `�I/711� <br /> Owner's Slgnature: Date� <br /> Last Updated:January 2016 <br />