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, � � RECEIV�D <br /> : � . . <br /> City of Orono �'�5' NOV 2 9 20'� <br /> Building Permit Application C�-�ypFORONO <br /> for New Structures or Additions <br /> Mailing Address: Permit number. �L'� k� �-���p <br /> PO Box 66 1�'� <br /> �O�Q Crystal Bay, MN 55323-0066 � Date received: �l"�-y " � �� <br /> '� Received b � � <br /> Street Address:' (� �`� Y: <br /> y ,�' 2750 Kelley Parkway�� '�' Plan review fee: <br /> �' L` Orono, MN 55356 <br /> tqkESH��� Main: 952-249-4600 Total Fee:;�\r, , , �N <br /> Fax: 952-249-4616 w�vv�.ci.orcno.mri.us +�-�J�'�V � �+� ���'��►�� <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: ) <br /> Job Site Address: �� v ��j <' ��1, -' ��- �, qy;;�; �w �j J� J <br /> Will this be a Parade of Homes, Remodelers Sho ase Home or other Display Home? ❑ Yes No <br /> lf yes,a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shutt/e bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# `�" ° Expiration Date: <br /> Phone: cell S office <br /> Mailing Address: �� a G izy2 << S �t � ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER WFORMATION:� ;� <br /> Name: J �(�i�'� �C �1 -' <br /> Phone (day): • �': . ., , <br /> Address: �� � Cit : ZIP: J���y I <br /> Email and/or Fax ;Q�Q�����q�p« � ����, �M� <br /> � <br /> ARCHITECT/ ENGINEER�F�O��RMAT�� ��S <br /> Name: ;L� ej'If�i <br /> Phone (day): � � v� <br /> ��i���L' �-�L r3�7r i�'IL- <br /> Address: �� 5:3;� c� "� City: <br /> Email and/or Fax: �.X��/�'n-' ZIP� SS-�_3 � <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> Q,New Construction Water Supply <br /> ❑ Single Family with ❑ Accessory Bldg./Garage <br /> �.(addition attached garage ❑ Deck �Public Sewer <br /> ❑Accessory Building � Single Family with ❑ Office/Commercial <br /> ❑ Relocation detached garage ❑ Residence ❑ Private Sewer <br /> ❑ Other:(specify) ❑ Multiple Family/Condo ❑ Retaining Wall(s) <br /> ❑ Public 4-feet or greater ❑ Public Water <br /> *''Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review&permits. ❑ Industrial ❑-Warehouse �Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ pther. (speCify) ��Ot r speCify) <br /> 15320 Minnetonka Blvd ���� <br /> Minnetonka,MN 55345 <br /> Phone: 952-471-0590 3 yrql.�p� <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> / v ✓ <br /> Estimated Construction Valuation (excluding land) $ /' <br /> Packet Last Updated: August 2015 <br /> Page 21 <br />