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0311212015 12:47 Les Jones Roofing,Inc. M=17= P.0021002 City of Orono . Building Permit Application for Maintenance / Replacement / Remodel (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) A r� Mailing Address: Permit number: {V PO aox 88 Crystal lay,MN 55323-0066 Date received: Street Address: Received� � by: 2750' Kell Parkws� Kelley Y Plan review fee! ��gkBSrt0�wG Orono,MN 55356 Total Fee:. { Q441 Main: 952-249-4800 Fax: 952-249-4616 > ,d,prono.mn.us This application form must be completed in full and all required information must be submitted. GENERAL INFORMATION: Incomplete applications will be returned. (Please print) Job Site Address: 2 LD L34' A060 Will this be a Parade of Homes, Remodelers Showcase Home or other Display Homed Yes El No (ryes,a spedel event pennk is required w8h Ponce Department and My Council epprovat 60 dos prior to the event Shuft bus service wN be require d unless appNcerrt demonstrates atrfilcleM on,'tte parking Is avatteble. Nonper►nitted events WAN not be allowed CONTRACTOR/APPLICANT INFORMATION: 'Pe/•o?-: 5W Name: r' / gy. Ww-q7- Ae-AaWrAb0FZU1 � State License# Expiration Date: Lead Certification Number: ,yqT. 4�p3IL-1' Expiration Date: 57j:tf/16-- (for work on homes that were constructed pilar to 7878 Phone: (Cell) (office) Mailing Address: City: ZIP: Contact Person: Applicant is: Contractor / Homeowner icrrcto one) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: .J A-Cy-i E f lLe M,4,J Phone(day): %E2 - q7/• 9126, Address: City: ZIP: Email and/or Fax: PROJECT INFORMATION: Overall prpject description: Type of Project: Any earth movement may also require ❑Door(s) ❑Remodel ❑Fire Damage MCWD review&permits: Re-roof,asphalt [3 Repair ©Storm Damage Minnehaha Creek Watershed District(MCWD) O Re-rooi,cedar 18202 Minnetonka Blvd ❑Restoration Q Water Damage Deephaven,MN 35391 ❑Re-roof,other(spec[M ❑Siding ❑Other:(specify) phone: 952-471-0590 Fax 952-471-0662 ❑Wlndaw(s) www.minnehahacraek.om Estimated Construction Valuation of Project(excluding land) $ 2:& 831 `� APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the Information supplied Is true and correct to the best of blamer knowledge. The applicant redognlzes that they are solely responsible for submitting a complete application being aware that upon%lum to do so,the staff has no alternative but to reject it unto It Is complete; • Some or all of the Informatlon that you are asked to provide on this application is classified by State law as elther 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 data Is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies required by law. If you refuse to supply the idormation.Me application may not be issued. -Applicant's Signature: G'.US ANA J Date: 1,a /S" Owner's Signature: __ ____ Date: Last Updated-January 2016