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City of Orono �3�� �3 <br /> Building Permit Application (�.�I- 3��7�'� <br /> for New Structures or Additions � <br /> �_-,> Mailing Address: Permit number: - ��C y ( <br /> �,0,�.� PO Box 66 <br /> � ; � Crystal Bay, MN 55323-0066 ?U- Date received: �_ `( � <br /> � � I <br /> � �'ay ab�;, ,,�� Sfreet Address:' eceived by: <br /> .�,L G�/� 2 7 5 0 K e l l e y P a r k w ��'��(;� P lan review fee: � . � � �C� <br /> �kESH�/ 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. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: l��- ����"�"— `���� :��"" .�'"��'�,:c..� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes f�No <br /> /f yes,a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shutt/e bus service wi//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: ;:.,.�,4a- 4°`.,���r, �t�►--'4�� <br /> State License# (��G �' Expiration Date: 3 �1 ,?�1�' <br /> Phone: �9y y �ay�{- — q q-�� (office) (cell) <br /> Mailing Address: l5t�1Z �-lw Cit : M�����_�'����-ZIP: � <br /> Contact Person: c,e} � o� Applicant is: ontract / Homeowner (Circle One) <br /> Email and/or Fax: ��sfi�..to u� �+ {..-�G�� ��r..��; ��-�t <br /> PROPERTY OWNER INFORMATJON: <br /> Name: b�r.�.�.r�" � �-1-n.�w�_ i;:�!�•s.�'� <br /> Phone (day): �t2 !�f- -�'j��°� <br /> Address ��M'1� ,�� �',;�� City: ZIP: <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: ���" �.>v����f�-- {��t 1`'v. <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal 8� <br /> Water Supply <br /> ❑ New Construction ,�Single Family with ❑ Residence <br /> ,�Addition attached garage �arage/Accessory Bldg. ❑ Public Sewer <br /> ❑Accessory Building ❑ Single Family with Deck <br /> ❑ Relocation detached garage ❑Office/Commercial ❑ Private Sewer <br /> �Other: (specify) �^�-�F a r�,`""" ❑ Multiple Family/Condo ❑Warehouse <br /> ��•,,�,:-s�����„ ❑ Public ❑ Storage ❑ Public Water <br /> *`Any earth movement may require ❑ Commercial �"Other(spe,,,c.��Y) <br /> MCWD review 8�permits. ❑ Industrial �`il�l'�'T"�i'?�" �� ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (speCify) �` <br /> 18202 Minnetonka Blvd }�'°�'ih�''a���. <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ � �� �`� <br /> Packet Last Updated: 03-06-2012 <br /> -21 - <br />