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05l25l2012 10:11 Les Jones Roofing,Inc. �A�q85�8817009 P.0021002 <br /> . �. +► <br /> City of Orono <br /> Building Permit Appiication for Maintenance ! Renovation <br /> windows, doors, siding, re-roof, etc.) <br /> Malling Addresa; permit number: o� -O D T`-j <br /> Q�O�Q Cryatal8ey, MN 55923-0088 Dete recelved: - 5� <br /> Sfreef Addiess: Recelved by: - <br /> 2T50 Kelley ParkwaY Plsn reWew fee• <br /> � �,6� Orono,MN 55358 <br /> 7otal Fae: ��, �� <br /> Main: 952-249-4600 Fex: 952-249-4816 }�,qro�o•mn•�s <br /> Th�s�pplicet�an fonn must be wmpleted In full and sll requlred Informatlon must be submltted. <br /> tncomplete appllcatlons wlll be returned. (Please pHnq <br /> OENERAL INFORMATION: <br /> JobSiteAddress: %ypS ID/�f2K L7��V� <br /> WIII thls be a Parade of Homes,Romodelere Showcase Home cr vthe�Display Home? Yee No <br /> If yes,e ipsc/al.vent pe►m�k roqulrod n�th PWrca Deparfmont end C�jr CouncA epp►vvef 80 dey8 prda�to fhe eVs� Shu�le bu8 se►�s w�be <br /> Aqtdred un�eta eppHcant dsmonahaha au�c�nf a►Nalta pa�Mny Is evellpble. Nor►�pem►Rtod ever►ta w�not Da a�d. <br /> CONTRACTOR/APPUCANT INFORMATION: <br /> Name: �'oa �v iN6 /N <br /> State Llcense# (e p(os' Expiratio� Date: ,� / <br /> Lead Ce�tiflcatlon Number: /�T- —I Expiration Date: <br /> (for work on homos thst vwn eonat►vcte p�lo►to/97a <br /> Phone: ys�-Ssi- az�c coff�) c�u� <br /> Malling Address: �y. �� �� City: 7y�r/ ZIP: y <br /> Contact Person: � ,s ���, Appllcant ls:�Tj / Homeowner �c�ro�o ono> <br /> Email�nd/or Fex; les n � <br /> PROPERTY OWNER INFORMATIOId: <br /> Name: f�R�qn/ ,fJy�'h.�b'�. <br /> Phone(dey): S5�- y 7�- /�79 <br /> Address: Cit)►: ZIP: <br /> Email and/o�Fax <br /> PROJECT INFORMATION: <br /> Type of Pro ect: � Any eartfi movement may nqulre <br /> ❑Door(s) ❑Remodel ❑Flre Demege MCWD revlew&permlts: <br /> Minnahsha Creak Watershed Distrlct(MCWD) <br /> ❑Re-roof,asphait ❑Repeir ❑Stonr Demege 18202 Mlnnetonke Bivd <br /> ❑Re-�ocf,cedar ❑Reetoredon ❑Weter Damape Deephaven,MN 55391 <br /> Phone: 852-471-0580 <br /> �Re-roof,other(9pociiy) ❑Slding ❑Other.(spedty� Fax: 952-471-0982 <br /> �POA�t ❑Window(s) <br /> www.minnaha hacnek.ora <br /> Overall ProJect Descriptlon: <br /> Estimated Construction Valuation of ProJect(excluding 18nd) $ a. 9//. �� <br /> �--- <br /> APPLICANT ACKNOWLEDC3EMEN?: <br /> . Agrees to provlde all infonnation required or requestod by ths Building Dapertment; <br /> • C�rtifies that the InFonnadon supplled Is true and corred to the best of hisfher knowled�e. The applicsnt rewpnizsa that they <br /> ere solety responsible fvr submitting a complete epplicatlon bein8 ewere that upon fellure to do so, the steff hes no altemative <br /> but to reject it uMil it is complete; <br /> • Some or�II of tht infortnatlon that you ere askod to provide on this application is classifiod by State law as oithsr pfirete or <br /> confldentlal. Privete dat� is inform�tion which gsnerelly cennot be glv�en to the public but can be �Iven to th� 'ubjaa of the <br /> data. ConBdentisl dsts is inbnnadon whldt genereUy oennot bv oiven to eith�r the public or ths �ubject of ths dete. Out <br /> purpose and IMended use of this ir�formation is to annueily update our records and recards of other govemmvntat a�enaes <br /> ulred b law. If ou refuse to a the Informsdon e a li ' m m �ot be issued. <br /> ApplfcanYs Signature: ' Dete: 5����/� <br /> �..t i��.+.►e.r• nar��n�� <br />