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, � . City of Orono Building Permit Application for New Structures or Additions Mailing Address: /��0,j�. PO Box 66 Permit number: da/�— DD$75 �Q � Crystal Bay, MN 55323-0066 Date received: B`�� ' �� �I ��' '� I Received b : S 1�,a ^'�'�z� '` �,� Street Address:' y ��',�, �,. �`;`�,� �ti/ 2750 Kelley Parkway Plan review fee: �t��o� Orono, MN 55356 ___-' Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: �. �D� �Tµ�'V�r , lU� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No If yes,a special event permit is requrred with Police Department and City Councif approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking rs available. Non-permitted events will not be allowed. CONTRACTOR PPLICANT INFORMATIO . Name: <j'o H-IV �, L State License# iVo N�' Expiration Date: Phone: ��'- 7�3 `l �.,�j �. ! 1 3 0 (office) (cell) Mailing Address: po o ! 77 Cit : LoNG LAKc` ZIP: S S� Contact Person: �p f�-�/ /-F, L C /ti Applicant is: on ractor / Homeowner (Circle One) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: �"O f'1�O1� f'�"� �-C/ti Phone(day): _23 9 z 9 Z / / 3 O Address: �„78r0 6 7"�t Qt-b/E', ,V� City: �.aN6 �K� ZIP: 5-S"3 S"� Email and/or Fax ARCHITECT I ENGINEER INFORMATION: Name: Phone(day): Address: City: ZIP: Email and/or Fax: PROJECT INFORMATION: 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal 8� Water Supply ❑ New Construction ❑ Single Family with ❑ Residence ❑Addition attached garage ❑ Garage/Accessory Bldg. ❑ Public Sewer ❑Accessory Building ❑ Single Family with ❑ Deck ❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer ❑ Other: (specify) �� LO G�'T/ON ❑ Multiple Family/Condo ❑Warehouse ❑ Public ❑ Storage ❑ Public Water '"'Any earth movement may require ❑ Commercial ❑ Other(specify) MCWD review&permits. ❑ Industrial ��-2�� ❑ Private Well Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) �� 18202 Minnetonka Blvd r?d..._�� --�� t/�a 'Q �R�� vQ�✓1: Deephaven, MN 55391 �� i"y-- Phone: 952-471-0590 �j/�}"/�,�� Fax: 952-471-0682 www.minnehahacreek.or Estimated Construction Valuation (excluding land) $ t�Q��` _� ��c,g-T� �j,9�Z� �rNn co NI/�7 r '�o G•�RA-G� ,�y iNsT,��r� 3 �� 17Qaa75 l � �. - . .