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<br /> CITY OF ORONO
<br /> BUILDING PERMIT APPLICATION
<br /> FOR NEW STRUCTURES OR ADDITIONS
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<br /> j�Q� Mailing Address: Permit number. p�d Q�,�j�
<br /> � � PO Box 66
<br /> �1 O Crystal Bay, MN 55323-0066 Date received: _�/ � / 7
<br /> � . Received by: 7�y1�
<br /> `�; ,, Street Address: _ _ � �
<br /> �`'� G: 2750 Kelley Parkway ' ����, Plan review fee: v+�/. � �",
<br /> ��KE.S�{��� Orono, MN 55356 �� C�1c,r (��t'�-, 7 ;
<br /> -- - ...._ ._. _ _�� ��� ...
<br /> � Main: 952-249-4600 Total Fee: � y '�
<br /> Fax: 952-249-4616 www.ci.orono.mn.us .� ! .+ ��>G�_
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<br /> This application form must be completed in full and ail required information must be submitted. �y��t� �_h� ��
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION: �.
<br /> Job Site Address: ,��'�;v s}�� �k. , � ��. �d j�;��, 11 b� �3a�� �p /.30(}
<br /> Will this be a Parade of Homes, Remodelers Show ase Home or other Display Home? ❑ es �No
<br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shutt/e bus service hTill 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: ��or.z��_ c;'(� i..L.C-
<br /> State License# Expiration Date:
<br /> Phone: (cell) �i a- 3�3-3 3:�� (office)
<br /> Mailing Address: �I ln 1\'�` A.,� S�; City� �.\�,�k,��� ZIP� �;3y3
<br /> Contact Person: Ai�x �,or�+, Applicant is: Contractor / Homeowner (CircleOne)
<br /> Email and/or Fax: �,,,\izx �, e,,;d��t�,s .�,,,.,
<br /> �
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: - - U��r�� ��,t�' L,C..,L_ - rl\.a.�c �.1�, -��+
<br /> Phone (day): (�,ia- 3t�;3 - 3 3�a.�
<br /> Address: y�v ���►�- A-,,t. S�• City: NG,�k,.,t ZIP: 5�343
<br /> Email and/or Fax _ �\e.x ��_ rr„d1�.,,��4�s� .c�r�
<br /> ARCHITECT/ENGINEER INFORMATION:
<br /> Name: l.�i�1�.�� �►r �:��� }�
<br /> Phone (day): �jS:� - `�'i I - �Ji:- -���
<br /> Address: /S �i.:'n f,� ,.��� , City: f-lopk�nr ZIP� 5'S3�/'
<br /> Email and/or Fax: c�I n � w;ik.�<a�r�, cL,,�
<br /> PROJECT INFORMATION: Description of project:
<br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal &
<br /> ❑ New Construction Water Supply
<br /> ❑ Singie 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) re���� ❑ Multiple Family/Condo ❑ Retaining Wall(s)
<br /> ❑ Public 4-feet or greater ,gf Public Water
<br /> "*Any earth movement may also require Commercial ❑ Storage
<br /> MCWD review&permits. � Industrial ❑Warehouse
<br /> Minnehaha Creek Watershed District MCWD ❑ Private Well
<br /> ( ) ❑ Other: (specify) ❑ Other(specify)
<br /> 15320 Minnetonka Blvd
<br /> Minnetonka,MN 55345
<br /> Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> www.minnehahacreek.orq
<br /> Estimated Construction Valuation (excluding land) $ �/z'� i 6�"�`�`-' � �� RECEIVED
<br /> JAN � � �Q17
<br /> Last Updated: January 2.016 C�•�.Y��OR�Nd
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