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r <br /> , . � . � �-� � � 9_ 3 <br /> City of Orono ,, � � / ' /�/ <br /> Buildin Permit A lication � � `� <br /> J pp <br /> for New Structures or Additions <br /> Mailing Address: p'� ��j —� � 9 <br /> O PO Box 66 Permit number: <br /> � �� Crystal Bay, MN 55323-0066 Date received: �P `� g��3 <br /> Street Address:� Received by: <br /> y ,� 2750 Kelley Parkway Plan review fe : <br /> F c,` Orono, MN 55356 � / 04�/� <br /> `qkESHO�� Main: 952-259-4600 Total Fee: J / � <br /> Fax: 952-249-4616 �vv�N�,v ci or�no mo 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: i , � <br /> Job Site Address: I ���'�� C�t.-cr�T ���.� <br /> Will this be a Parade of Homes, Remode�ers Showcase Home r other Display Home? ❑ Yes No <br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service ill e <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: j1'1 l� � 1.��GCU �Ci�= ���$ <br /> State License# O c�0 � i 7� Expiration Date: 3 -.�/ - �f1/ <br /> Phone: cell CQ I:2 -� O- "7 office Z — — 4� <br /> Mailing Address: � � ,4 � Cit : ' �� � ZIP: �- - <br /> Contact Person: �� G�5 Applicant is: C rac / Homeowner (CirdeOne) <br /> Email and/or Fax: �i4x �5 Z���5��� 5�'/ lo��n'lin�'��'SatQ r'�-!S� -� �Y�'l <br /> PROPERTY OWNER INFORMATION: ' ���� 1 �� <br /> Name: � �,�nL� c,�� <br /> Phone (day): �'�1,�. -.23�-' Cot� �7� <br /> Address: ( OO p� Cit : �Ca'�t� ZIP: -���.5rc <br /> Email and/or Fax '�'jn - o l . t.c�•-r� <br /> ARCHITECT I ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal 8 <br /> Water Supply <br /> ❑ New Construction ingle Family with ❑ Residence <br /> ❑Addition attached garage ❑ Garage/Accessory Bldg. ❑ Public Sewer <br /> ❑Accessory Building �Single Family with ❑ Deck <br /> �elocation � detached garage ❑ Office/Commercial ❑ Private Sewer <br /> ther. (specify) ��I�LR'� �2�i1��' �] Multiple Family/Condo ❑Warehouse <br /> �� ❑ Public �Storage ❑ Public Water <br /> "*Any earth movement may require ❑ Commercial Ot er(spe ify) <br /> MCWD review& permits. ❑ Industrial �{'�-n�DuS� ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other' (specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> P hone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) � 1'�' � � ��o <br /> Packet Last Updated: 04/19/2013 <br /> Page 22 of 23 <br />