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� C�ty o� ��ono <br /> ' �ui�c�in� �erm�t �4p��ecation <br /> for IVew S�truc�ures or �4ddit�ans <br /> Mailing Address: Permit number: � <br /> �Q� PO Box 66 �,, � �- r' � : ' < <'� C� <br /> o Crystal Bay, MN 55323-0066 _ yw Date received: C�� \ -�(� <br /> 0%' ��P — <br /> StreetAddress:' ��-� Received by: ��--� <br /> y� ,� 2750 Kelley Parkwa y g P l a n r e v i e w f e e: j�� (� �.��i �( � f• <br /> c. Orono, MN 55356 f <br /> �'�k E S H o��' Main: 9 5 2-2 4 9-4 6 0 0 Total Fee: l $Q. 7 3 <br /> Fax: 952-249-4616 �vv✓�v.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. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address �p,,L <br /> Will this be a Parade of Homes, Remodelers Showca e Home or othe isplay Home? ❑ Yes �No <br /> /f yes, a specia/event permit is required with Po/ice Department and City Council approval 60 days prior to the event. Shuttle bus service i�4ll be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be a!lowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: c� <br /> State License # ( Expiration Date: <br /> Phone: cell office <br /> Mailing Address: O ,,v� Cit : ZIP: <br /> Contact Person: Applicant is: � / Homeowner (Circle One) <br /> Email and/or Fax: ,�,,;,,,,,, ,,a����,�,���� �� <br /> PROPERTY OWNER INFORMATION: <br /> Name: C`� rn n ��/-���lti..�►(��� <br /> Phone (day): <br /> Address: Cit : �. Z�P: <br /> Email and/or Fax ^- <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: Citv: Z�p� <br /> Email and/or Fax: <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: Cit : 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& <br /> ❑ New Construction Water Supply <br /> ❑ Single Famity with ❑Accessory Bldg./Garage <br /> ❑Addition attached garage ❑ Deck <br /> ❑Accessory Building ❑ Sin le Famil with ❑ Public Sewer <br /> g y ❑ Office/Commercial <br /> �elocation Q ��/ Q /' detached garage ❑ Residence <br /> Other: (specify) IJ�TGt K2t��f ❑ Septic <br /> ❑ Multiple Family/Condo ❑ Retaining Wall(s) (Compliance certificate <br /> ❑ Public 4-feet or greater may be required) <br /> *"Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse <br /> ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) Other: Spe Ify) Other(speCify <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 �'f�Js,�,��� � ❑ Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ <br /> Packet Last Updafed: January 2016 <br /> Page 21 <br />