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,. <br /> . �Q�� �aw �?��`'1 <br /> " / � <br /> �-� �-� City of Orono C�" � � � <br /> ? `� 1 � �(P. <br /> �c�,� Building Permit Application � <br /> �- �c�-�3 for New Structures or Additions <br /> Mailing Address: �i3^ Z <br /> ;�(�A,�� PO Box 66 Permit number: <br /> / `v0 \\ Crystal Bay,MN 55323-0066 Date received: —( �— �� <br /> r � Received b <br /> � Sireet Address:� Y= <br /> I�� ,�j 2750 Kelley Parkway Plan review fee: �� $ <br /> � � �� Orono,MN 55356 — <br /> ��kFSHo�� Main: 952-259-4600 Total Fee: ����— ��� <br /> �—"� Fax: 952-249-4616 <br /> This apptication form must be completed in full and all required information must be submitted. <br /> I�complete applications will be retumed. (Please print) <br /> GENERAL INFORMATION: tC / <br /> Job Site Address: Z.Z$0 s�l7d(i1d0D0 �/L . LeNG �/Q�,'g; �� 7 J,3,5�0 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No <br /> lf yes,a special event permit is requiied with Police Department and City Councif approva160 days prioi to the event. Shuttle bus service wi8 be <br /> required unless applicant demonstrates sufficient on-site parking rs avaifable. Non-permitted events will not be aftowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: C C'IL O l�/'�Nl�s <br /> State License# �G�j 92�7?J Expiration Date: � <br /> Phone: cell • � office ' 3sa2 <br /> Mailing Address: 2S �L LS I D �V10 �3d Cit : ZIP: <br /> Contact Person: QQppy �H��p Applicant is: on rac / Homeowner (Circle One) <br /> Email and/or Fax: �{2pDY o $G H R�1�Cd1Z'1I�AN/i!S. Gd i'YI <br /> PROPERTY OWNER INFORMATION: <br /> Name: $�L L (;�'S7 <br /> Phone (day): <br /> Address: ZZ,gs S�'�1�Ibb/pa{J Dtft.• City: �^la �./4jL� ZIP: SS3s( <br /> Email and/or Fax (.�Ls'Sfi A'� Sf-�er�[)eGTD R . CbM�I <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: ����N�f <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal 8� <br /> Water Supply <br /> ❑ New Construction Q�Single Family with �j Residence <br /> �$Addition attached garage ❑Garage/Accessory Bldg. ❑Public Sewer <br /> ❑Accessory Building ❑ Single Fam�1y with ❑Deck <br /> ❑Relocation detached garage ❑�ce/Commercial �Private Sewer <br /> ❑Other: (specify) ❑Multiple Family!Condo ❑Warehouse <br /> ❑Public ❑Storage �J Public Water <br /> kkAny earth movement may require ❑Commercial ❑Other(specify} <br /> MCWD review 8 permits. ❑Industrial ❑Private Well <br /> Minnehaha Creek Watershed Distrid(MCWD) ❑Other.(spec'rfy) <br /> 18202 Minnetonka BNd <br /> Deephaven,MN 55391 <br /> Phone: 952-471-059D <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.o <br /> Estimated Construction Valuation (exduding land) � �00� �00, � <br /> Packet Last Updated: 04/19/2013 <br /> Page 22 ot 23 <br />