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, Cityr af Qrono <br /> �uilding Permit Application <br /> ' - for �New Structure� or Additions <br /> ' Mailing Address: Permit number: • () j <br /> �Q� PO Box 66 ' C � <br /> Q Crystal Bay, MN 55323-0066 Date received: <br /> Street Address:' R <br /> ' ,� 2750 Kelley Parkw '� <br /> y�' �~ Orono, MN 55356 �� ��'���r Plan�e�iew- e: ��( <br /> t9xfSH0�� Main: 952-249-4600 Total Fe�e.�� -- - <br /> Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information rnust be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 2oLq- �,�, o� o( ��,�,p �/vi .J ,S�3q � <br /> Will this be a Parade of Homes, Remode ers Showcase Home or other Display Home? ❑ Yes �N�o <br /> If yes,a special event permit is required with Police Department and Ciry Council approva/60 days prior to the event. Shutt/e bus service lwll be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non permitted events will not be allowed. <br /> CONTRACTOR/APPUCANT INFORMATION: <br /> Name: 3 -�,�. -� �u l�h �c1�c� <br /> State License# Expiration Date: <br /> Phone: (cell) (i 670 ,fD 4- (office) <br /> Mailing Address: ?.ot4 Sln.�� � Cit : 8r�wo � 5�39/ <br /> Contact Person: C1,a-� Applicant is: Contractor / own <br /> (Circle One) <br /> Email and/or Fax: Q�.,(�_c,.„,�o��� v,,,-�n• ,�,,•.,u--, F �,w.. <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZI P� <br /> Email and/or Fax <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: G-c.�^c.. �e�uk.P/� - ��J.Sa CA.n,(�I���S I �c-• <br /> Phone(day): �SZ_ �4 4- -j� 3 7 <br /> Address: 7oz9 Cow�a���•c �� � City: ��.;�� ZIP� �r �39 <br /> Email and/or Fax: ('_ �sso�a (a �,,,�,,,,�. �-�,.� <br /> � <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: Q�o�� a,nJ R�.�o)a� o�} 1�w�� and J�PJ <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> ❑ New Construction Water Supply <br /> ❑ Single Family with ❑ Accessory Bldg./Garage <br /> ❑Addition attached garage ❑ Deck <br /> �4ccessory Building ❑ Single Family with ❑ Office/Commercial � Public Sewer <br /> ❑ Relocation detached garage ❑ Residence ❑ Septic <br /> ❑ Other:(specify) ❑ Multiple Family/Condo ❑ Retaining Wall(s) (Compliance certificate <br /> ❑ Public 4-feet or greater may be required) <br /> '�`Any earth movement may require ❑ Commercial � Storage <br /> MCWD review 8�permits. ❑ Industrial Warehouse <br /> Minnehaha Creek Watershed District(MCWD) Q Other: s eCi ❑ PubllC Water <br /> ( p fy) ❑ Other(specify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 _ S�e ❑ Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ ( � �6 d <br /> —�--� <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />