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. � � � � � <br /> CITY OF ORONO � <br /> BUILDING PERMIT APPLICATION � � -�J�, 9�- <br /> FOR NEW STRUCTURES OR ADDITIONS <br /> .__ .. <br /> Mailing Address: Permit number: p?Q� -QLS � <br /> �`'���`, PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: / - a2!-/ <br /> ', � Received by: <br /> ��s �� � Street Address:' <br /> ;� ' �,� � 2750 Kelley Parkway Plan review fee: �7 9a�• �d <br /> ` �.�;��i1ii{`���`;' Orono, MN55356 �O/7—D/5��. <br /> _ Main: 952-249-4600 Total Fee: <br /> Fax: 952-249-4616 �,•:�tiv.ci.o=o��c�r:.��.i;s <br /> This application form must be completed in full and all required information must be submitted. �1��� <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �]�j sj�,�jyi✓�;�� ��� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No <br /> If yes, a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will be <br /> required un/ess applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFOF�MATION: <br /> Name: �. C $d � � 5 �to0' <br /> State License# n2D�li Expiration Date: 3 3 0 <br /> Phone: (cell) �,�2_C���,��� (office) 95 2 - 935- �'�i�Z <br /> Mailing Address: o niC ✓ � '� 6 Cit : �/ ZIP: S ,6 <br /> Contact Person: �� 'j'v,��qy�,G�'„/ Applicant is: ontracto / Homeowner (Circle One) <br /> Email and/or Fax: C��(rI,�;C,Qqy�EQ, �y� <br /> PROPERTY OWNER INFORMATION: <br /> Name: 7i2AVIS f�i�'�/S�c�6fR- <br /> Phone (day): !(�Z�.��- �93y <br /> Address: (�'�.���E Gj_ City: ��¢n/ ZIP: ,s$�/2.3 <br /> Email and/or Fax I��,,,SB��!�Q � q�o, �� <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: �(.�.4�/D�iae- ���b.✓ (o/Gt��� <br /> Phone(day): 9S'Z-�/7� - g 7�7 <br /> Address: l�p� '' `��� City: ����"�Q'l�,¢ ZIP: SS�9_� <br /> Email and/or Fax: ������q,ypnQ�`,rLpJ� Covr� <br /> PROJECT INFORMATION: Description of pro ect: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> � New Construction �Single Family with ❑Accessory Bidg./Garage <br /> ❑Addition attached garage ❑ Deck 0 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 also require ❑ Commercial ❑ Storage <br /> MCWD review 8�permits. ❑ Industrial ❑Warehouse ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) ❑Other(Specify) <br /> 15320 Minnetonka Blvd <br /> Minnetonka,MN 55345 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> i:.. :�=��6at?at;re�:k.crr <br /> Estimated Construction Valuation (excluding land) $ 92�� �QC� REC�lVED <br /> NOV 21 2011 <br /> Last Updated: January 2016 <br /> ` c�N oF oRONo <br />