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09107l2016 13:43 Les Jones Roofing,Inc. �A��528817009 P.001l003 <br /> . • <br /> • ' .����9� City of Orono <br /> Building Permit Application for Maintenance / Rep[acement / Remodel <br /> i.e. windows, doors, siding, re-roof etc. — NO STRUCTURAI. �XPANSION <br /> ,�} Malkng Addresa; pertntt number. ' (�b � <br /> 0 <br /> � �v� Crystal Bay,MN 55323-0088 Dete rocaived: �� <br /> SEreet Address: Received by: <br /> �� 27�lGelley ParkweY Plan revlew fee: � ay <br /> t,���sH ��,� arono,MN 55356 <br /> Tot81 Fee: I�I'�P <br /> Ma(n: 952 249-4600 Fa� 952-249-4616 ' <br /> This applicatfon form must be completed In full and all required information must be submi�ed. <br /> Incamplete appiications will be returned. (Please pNnt} <br /> (3ENERAL INFORAAATION: <br /> Job Site Address: ���� LAK�'1//EGtf 1/�: <br /> Will thts be a Parade of Homea�Remodelers Showcase Home or other D splay Home? es No <br /> 11 y�9s,a apeCle!eve►x permlt la►squlrod Wlth Polk:s Depertmellt end Clty CowxU epproval BO deys prbr to the e�ronk 3huffla bus servk�e w�Be <br /> roqulrod unlesa appNcalk demonaN�tsa au119c1ent on�lts parkb►g ls avallab/s_ Non-ps►n►kted evoents wN!rrot be slbwed. <br /> CONTRACTOR I APPLICANT 1NFORAAATIQN: <br /> Name: /_.� �Il Fj (��G <br /> State License# 5 p Expiratton Date: ,�/ � <br /> Lead Certification Number: /(l,¢�. �p 3'72 .�, Expiration Date: ad <br /> (for work on home�thet were conatrtrcted prlor tn 7978 <br /> Phone: (cell) (�v� • � - % � � (offioe) 9J`"��•��/� ��2 <br /> MalUng Address: �h �7���-- Ciry: � ZIP: S✓�' ZQ <br /> ContactPerson: y S yQ Applicarrt' _ Ccntractor Homeowner �ckcaaa� <br /> Emai)and/or Fax: �y . 5 Q, <br /> PROPERTY OWNER INFORAAATION: <br /> Name: <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall ro'ect descri tion: <br /> Typa of Projact: Any earth movement may also nqulro <br /> ❑ r(s) ❑Remade{ ' ❑Rro Damage MGWD revtew 8 permlte: <br /> Re-roof,aaphelt ❑Repalr ❑Storm Demage Minnshaha Creek Water�hed DlstrlCt(MCWD) <br /> ❑Re-roof,cadar 18202 Mfnnetonke 8Nd <br /> D R�storadon ❑Water Damage Deephave�,MN 65351 <br /> ❑Re-roof,ot�er�sp�cNy> ❑Siding D Other. (specityy Phone: A521171-0590 <br /> Fax: 852�71-0682 <br /> ❑Windaw(s) www,minnehah�creek.cra <br /> Estlmated Constructlon Valuation of Projeot(excluding�land) a �'�. <br /> APPLICANT ACKN0INLEDGEMENT: <br /> . Agrees to provide all InPormation required or requested by the Building Department; <br /> • Certifies that the informetion supplied is true a�d w�ract 10 the b9st of his/her knpwledge. The applEcarn recrognizes that they aro <br /> solely responaible for submitting a complete appllca8on being awere that upon feiluro to do so,the etaff has no sd6amative but M <br /> rejed it until it is complete; <br /> • Some or a(I of the infomnatfon that you are asked to provide on this eppOcstlon Is dassHled by Stete lew aa eBher private or <br /> confideMial, private data is irrformadon whid�ganerally csnnot be given to the publlc but can be given to the subject of the dsta. <br /> ConBdentlel data ls Inlbrmatlon whfch generalry cannot be given to either#�e public or the SubJect of the data. Our purpose end <br /> intended use of this information is to 8�nnually upda�our records and records of other govemmental agenaes required by law. If <br /> ou refuse to su I dte 1 rmat�on the a Ilcation me not be leeued. <br /> Applicant's Signature; Date: ��rl�/l <br /> Owne�'s Signature: Date: <br /> Last Updated:January 2015 <br />