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-. .. <br /> � �1` City of Orono <br /> ���� Building Permit Application � � �S <br /> ��9 <br /> for New Structures or Additions <br /> Mailing Address: Permit number: �/ —005�� <br /> �,�,� PO Box 66 <br /> %/ � Crystal Bay, MN 55323-0066 Date received: 7 /� <br /> ( <br /> �� �� `� � Received b <br /> �a 'y��t�� ` a.�, Street Address:' y� � <br /> ��'� ' ,� �,�.� ��� 2750 Kelley Parkway Plan review fee: T> . �'�'f <br /> '���rvo4� Orono, MN 55356 O _D <br /> �„___sx./ oZ / d S <br /> � --`� Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: � , <br /> Will this be a Parade of Homes, Remodelers Showcase Home or o er Display Home? ❑ Yes No <br /> If yes,a special event permit is required with Polrce Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT I FORMATIO� <br /> Name: �-�jf�,����yD + <br /> State License# � Expiration Date: ��;� , <br /> Phone: ` office , cell <br /> Mailing Address3 ' � Cit . �, ZIP: <br /> Contact Person: � Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: o � � , <br /> PROPERTY OWNER INFORMATION: <br /> Name: C ' <br /> Phone (day): , . `7 � <br /> Address: Cit :�� ZIP: <br /> Email and/or Fax � r C c� , <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: ���-�������'�' �N��1� <br /> Phone (day): � � � <br /> Address: �'' � � Cit : � ZIP: ��" <br /> Email and/or 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 �Residence <br /> ❑ Addition attached garage ❑ Garage/Accessory Bldg. ❑ Public Sewer <br /> ❑ Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial � <br /> Other: (specify)� �1\! ❑ Mu1ti le Famil /Condo � Private Sewer <br /> TS�}a p y ❑Warehouse <br /> �� �� ❑ Public ❑ Storage �Public Water <br /> *"Any earth move erri nt m req iG"re' ❑ Commercial ❑ Other(specify) <br /> MCWD review 8�permits. ❑ Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ I��r� , <br />