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From:LES JONES ROOFING 1 952 881 7009 08/18/2010 15: 18 #249 P.002/002 <br /> City of Orono <br /> Building Permit A�plication for lnternal Work <br /> (windows, doors, sidin , re-roof, etc. <br /> MailinBAddress� Permlt number• c.��/�'�� ��G�,��.� <br /> �r�,j� PO Box 66 • <br /> 0 Q Crystal Bay, MN b5323-0066 Date received: � �/�i`�/� ' <br /> St�eefAddress: Received by: ��.� <br /> �� � 2750 Kelley Parkway Plan review fes: <br /> oa�' Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease prinf) <br /> GENERAL INFORMA7101�I• � , <br /> Job Site Address: � f C.�Z, <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o <br /> If yes,a special evenf permit!s requ/red wfth Pollce Departmenf end C/ty Council approvel 60 deys prlo�in the ev�nf. ShutHe bus sarvice // e <br /> required unless app!lc&nt demonstrates s�eient on-s/te park/ng is available_ Non perml[fed events will not be allowed. <br /> CONTRACTOR/APP ICANT If�OaRhMATION: �� ��- <br /> Name: ,_/ ' <br /> State License# �J Expiration Date: 3 � <br /> Phone: -� a, office <br /> cell <br /> Malling Address: `g� C� . �P: . s � <br /> Contact Person: �� Applicant is: ntracto / w H eowner (Clrcla One) <br /> Email and/or� S _ _ <br /> PROPERTY OWNER INFORMATION: <br /> � Name: <br /> � Phone(day): <br /> Address: ,�.t,�, �va �-e- <br /> Ci : di'1f� ZIP: <br /> Emai!and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may requlre <br /> ❑Door(s) ❑Remodel �CWD review 8�permlts <br /> ❑Water Damage <br /> ❑Wfndow(s) ❑ Re alr Mfnnehaha Creek Watershed District(MCWD) <br /> P ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Siding ❑Restoration Deephaven,MN 55391 <br /> ❑Other:(specify) Phone: 952-471-0590 <br /> e-roof ❑Flre Damage Fex. 952-471-0682 <br /> www.minnehahacreek ora <br /> Overall Pro'ect Description: Q�yF G� Yd0•�5 — ir��.t.Q s <br /> Estimated Construction Valuation of ProJect(excluding land) $ g�ry�- �rj <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> . Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a oomplete applicatlon being aware that upon failure to do so, the staff has no altemative <br /> but to reject it until It is complete; <br /> • Some or all of the information that you are asked to provide on this applicatlon is classified by State law as either private or <br /> �nfidential. Private data is information which generally pnnot be given to the public but can be glven to the subject of the <br /> data. Confidential data is information which generalfy qnnot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re ulred b law. lf ou refuse to su I the' ation the a licativn ma not be issued. <br /> Applicant's Signature: ����c�� Date: g— /D — /d <br /> Last Updeted: 05-04-2009 <br /> ,r, <br />