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<br /> City of Orono � � °��
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<br /> Building Permit Application
<br /> for New Structures or Additions _- �
<br /> ��-0�'� MarliPg�Bd�dr6s6s: Permit number:
<br /> ;jiQ 9 �wQ 1 Crystal Bay, MN 55323-006E Date received: �I
<br /> �` �
<br /> Received b
<br /> ��,� '�'{ - ,, ,� StreetAddress:' Y' q G�
<br /> ���,�, � ,�� �.`�'�' 2750 Kelley Parkway Plan review fee: 0 ► O �
<br /> ° + ����$ Orono, MN 55356
<br /> ��ESHOg'// o�ai - o00 53
<br /> �~__- Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us i
<br /> This application form must be completed in full and all required information must be submitted. �
<br /> Incomplete applications will be returned. (Ptease print) j
<br /> GENERAL INFORMATION: �
<br /> —>�,, -. i
<br /> Job Site Address: > � G� ; 5�v�^�!;'-� „^ ,
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No
<br /> ff yes,a specra!evene perrnit is required with Polrce Department and City Councrl approvat&0 days prior to the event. Shuttle bus service wr7! e
<br /> requrred unless applicant demonstrates su�cient on-site paricing is avarJabJe. Non-permrtted events wi7!not be aflowed.
<br /> CONTRACTOR!APPLICA T INFQ RMATION:
<br /> Name: �,1�`'/ f(l,�,F�i�^u`� ���} �
<br /> State License# (�,--.;..�.�4 � G L Expiration Date: � . �
<br /> Phone: �- z pqU office cell
<br /> Mailing Address —� - ;,�, ;��� �:^...! � " Cit : .���:.�L.:,%z� ZIP: - �� n
<br /> Contact Person: �� �,., Applicant is: Gontracto3' ( Homeowner (Circle One)
<br /> Email and/or Fax: �,« ,;.� l,¢?�>�,.�}c�.�,�.�;,.., .� �
<br /> �
<br /> PROPERTY OWNER INFORMATION: �
<br /> Name: `'����jj a��� �.�-�-� ;
<br /> Phone (day): /'� - "<---� '
<br /> Address ,� L ' << •M�4 -� Cit : r ^.',.-�'e:�� �� ZIP: �� �G:�. �
<br /> Email and/or Fax /� o l,.`x�,,,��,.� �`.� �; ,-�; ' :��, i �,,t ' I
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<br /> ARCHITECT/ENGINEER INFORMATION:
<br /> Name: G '� �
<br /> Phone(day): � � �3 - �p o I
<br /> Address: �t^>'�+';';? %�.:a.1-��,- ��,c� City: �1 (�J�, � lr?; ZIP: �.-, �', !�'"'.
<br /> Email andlor Fax: `
<br /> PROJECT INFORMATION: �
<br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal 8�
<br /> Water Supply
<br /> ❑ New Construction ❑ Single Family with I ❑ Residence !
<br /> ❑Addition attached garage � ❑Garage/Accessory Bldg. [�Q Public Sewer
<br /> ❑Accessory Building ❑ Single Family with ❑ Deck
<br /> ❑ Relocation � detached garage :QOffice/Commercial ❑Private Sewer
<br /> �Other: (specify) f r-��z� ?�-��-*�— ❑ Multiple Family/Condo ❑Warehouse
<br /> � ❑ Public ❑Storage ❑ Public W�ter
<br /> *'Any earth movement may require Commercial ❑Other(specify)
<br /> MCWD review�permits. Industrial ❑ Private Well
<br /> Minnehaha Creek Watershed District{MCWD} �Other:(speCify)
<br /> 18202 Minnetonka Bl�d
<br /> Deephaven,MN 55391 i
<br /> Phone: 952-471-0590
<br /> Fax: 952-471-0682 I
<br /> www.minnehahacreek.or '
<br /> Estimated Construction Valuation (excluding land) $ ;' ��; , �;,�Y�;,
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