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From:LES JONES ROOFING 1 952 681 7009 AA , 06/28/2011 14:27 #030 P.002/002 <br /> ` 1V` <br /> • � � <br /> �� �1 <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Ma1/Ing Address: Pertnit numbe�: d/�-» <br /> O•�O�O PO 8ox 86 <br /> Crystal Bay, MN 55323-0088 Date recefved: <br /> Sh�ef AddresB: ReCeNed by: <br /> � � 2750 Kelley Parkvvey Plan review f�ee: <br /> Orono, MN 68356 <br /> Ma1n: 952 249�600 Fa�c 952-249-4816 www.cl.orono.mn.us TnffiI Fee: / 3D. 35 <br /> This application form must be completed in full and all required iri#orrnetion muat be submitted. <br /> Incomptete application�wlll be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Add�s: <br /> Will this be a Parade of Homes.Remodelers howcase Home or othe��Isplay Home7 Ye� <br /> n y.s,.9pscra�e�►n�r�a���wr�Po�ce vep.�ar,�.,t e�d cuy aou►,a��P,o�eo�y:p.ror ro me evsr� snr�rao aus ss u ae <br /> requl�sd uMeas eppllcarM demonsb�tes sufllcfent o�rsNe pa�Mr�y/s eva/leblie. Non-p�imMted e►rents w!Il not be dlowed. <br /> CONTRACTOR/AP LICANT I RMATIO � <br /> Name: �.S d�..e..5��• ���-e_. . <br /> State License# Expiration Date: --�j _/ a„� <br /> Lead Certification Number: '7'jGj�7_ �4 3�7a"Z — / E�iration Date: �j'. a ._ 1�-- <br /> (fbr work on homos war+�constructvd pr/or to 1878 <br /> Phone: ,5� .. $$`/ a��f/ (office) (cell) <br /> Mailing Address: (,�j � w-- ' City. � ZIp: a <br /> Contect Person: �,�„ Applicant is: orrtractor / meowner �cm�e or�.� <br /> Email and/o� <br /> PROPERTY OWNF�R INFO�TION: �� <br /> Name: J� <br /> Phone(day): _ _ „5��3 <br /> Address: ' Clty: Qj'��.p ZIP:S�35"Yc <br /> Emall and/or Fsx <br /> PROJECT INFORMATION: <br /> Type of ProJec� Any earth mowmont mAy r9qulw <br /> ❑Door(s) ❑Remodel ❑Watar Damage MG'VW revlew 8 permits: <br /> Minnehaha Creelc Watershed Dist�id(MCWD) <br /> ❑Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephavan,MN 55391 <br /> ❑Sidin ❑Reaboration ❑Other.(specify) phone: 952-471-0590 <br /> of ❑Fire Damage Fa�c 662�71-0682 <br /> �e�tuw_m in nehahacreek_ora <br /> Overall Project DesccipUon: �aa � w�_ <br /> F_atimated Conatruction Valuat on of ProJoct(excluding tand) S ,S'a2 _ �Od �c?� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to provfde alf infonnatlon raquired or requested by the Building Departmer� <br /> • Certifies that the intormation aupplied Is true and correct to'the best of his/her knowledga, The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so,the etaif has no altemative <br /> but to roject it untll it is oomplete; <br /> . Some or all of the infortnation that you are eaked bo provide on thls application is cla�sified by State lew as either prlvate or <br /> conflde�al. Private data la infortnation which eenera(y cannot be piven to the public but cen be given to ihe subject of the <br /> data. Confldentlal dats Is Iniormation which penerally cannot 6e enien to efther the public or the subject of tha data. Our <br /> purpose and intended use of thia informatio ennually update our records and r�ords of othe�govemmental agencies <br /> uirsd b law. If ou refuse nbrma on fhe a lication ma not be issued. <br /> AppllcanYs Signffiure: Date: �-`� ��l� <br /> Last updated: 03-07-2071 <br />