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�_%_ � I'_(-; ��_>�% i c�� FI� Ct�"t�'F �,�-`,��!>, f- <br /> �' 1 'jb"��C�c� �-l—(p—���I -�o�L�7-UO �i3l <br /> liil�/ UI VfVIIU <br /> � �-�>i'r'; J,�• [Xt6�iPI��' <br /> auua�ng rermii N►pp��cauvn <br /> rvr �vew �iruciures or �t�vns <br /> __ MailP Bdox S6 ermii number: ,..,�( /_ I ( t � 3 Z- <br /> / <br /> � ��� ,', Crystal Bay.MN 55323-0066 Oate receiv�: '�%� <br /> �� � Sheet Address:' �° / Received by: � <br /> \1 275�Kelley Parkway� ��� ��� <br /> % ' :. _ Plan rewew fee: 3� . <br /> ���1,� Orono.MN 55356 ',," �( <br /> � ?k'rsrii�a� Main: 952-249-4600 -- __ _. Tota1Fee:----- —� <br /> " '""✓ Fax: 952-24�4616 www.ci.orono.mn us <br /> This applicafion form must be completed in full and all required infortnation must be submitted. <br /> Incomplete applicatio�u will be retumed. (Please print) <br /> GENERAL INFORMAl10N: <br /> Job Site Address: 7 � � ` <br /> 7�C ;� `� . ,��% <br /> Will this be a Parade of omes, Remodelers Showcase Home or other Display Home? Yes No <br /> M yes.a specia!event permrt�s raquired w2h Pol�ce DepaRmen!and City Counci!approva!60 days pnor to fhe event Shutl/e bus sernce wr be <br /> requued unless apptrcanf denronsfiafes suffiaent on-s�te parki�g rs availeble. fVon-permitted events wrlf not be aflowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: > � L <br /> State License# p� �xpiration Date: ---ZL�/ <br /> Phone: (cell) Z office) Z � <br /> Mailing Address: C � e �' ' it : �,,'t LG.ya ZIP: ' <br /> ContactPerson: ���ti�/u �,�,.- �� Applicantis: ontra ,, / Homeowner �c��iea,.� <br /> Email andlor Fax: �--� jv-�,.�d u �% /�h/�_/i c,u�t. /.�i., <br /> PROPERTY OWNER INFORMIATION: /� �/��� ',,,,-^ <br /> UOi�� ` <br /> Name: ----�_�i;�---_�C��S I I�V2'i���S='� -------__.._......— <br /> Phone(day): <br /> Address: bC S/.-:_r1.rv- n,- CrtY: L�/'t"+Q�'� ZIP: S��/ <br /> ��--...__.._.__.._:... . _ _..... <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INF012MATION: <br /> Name: cl� � <br /> Phone(day): � .- <br /> Address: t�Cf , Crt : �' F_ ZIP:.�S <br /> Email andlor Fax: � ��-- " ` 1� �`i[-iL�• i-a'�CG'i-G. r�.z, <br /> (� �� ,�I ,� , <br /> PROJECTINFORMAl10N: Description of ro�ecf: �.r����-I�-�/u� � � �, � �1��L'�1L������ <br /> --................._—........................_...................____............... <br /> i 1.�ype oT Project 2.Proposed Use 3.Structure Tjpe 4.Sewage Disposal& <br /> i Water Supply <br /> ;�New Construdion �Single Family with ❑Accessory 81dg./Garage <br /> ; ❑Addition attached garege ❑Deck ❑Public Sewer <br /> ; ❑Accessory 8uilding ❑ Single Family with ❑OfficelCommeraal <br /> ' ❑Relocation detached garage Residence ❑Pnvate Sewer <br /> ❑Other(specify) ❑Muftiple Family I Condo ❑Retaining Wall(s) <br /> ❑Public 4feet or greater ❑Public Water <br /> *`Any eaRh movement may require ❑Commercial ❑Storage <br /> MCWD review&pertnits. ❑Industrial ❑Warehouse ❑Private Well <br /> i P.9innehaha Creek Watershed District(M19CVJD) ❑Other(specify) ❑Othe�(spedfy) <br /> ! 15320 Minnetonka BNd <br /> i P.linnetonka,61N 55345 <br /> ; Phone�. 952-071-0590 <br /> i Faz: 952-471-0682 <br /> � www.mmnehahaaeek.o <br /> $ � C�L�1 <br /> Estimated Construction Valuation(excluding land) ��- / <br /> Packef Last Updated-August 2015 <br /> Pege 21 <br />