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City of Orono I°�t <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address. Permit number: 020/D-D®C,c ;iv <br /> or Cr Box 66 <br /> � Crystal Bay, MN 55323-0066 Date received: Di// (Y/ <br /> Received b <br /> ,. i a, Street Address: Y <br /> g lf.� <br /> Z.4' ti: 2750 KelleyParkway F' , .",;.4's <br /> o Plan review fee: <br /> ��kEsso4` Orono, MN 55356 <br /> Total Fee: 7/, -7/ <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: 7b(az I? <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? P Yes n 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 will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: tativI tci vt heoj c•-)-1e3 1-2-• <br /> State License# o3 8�tI/D 1 Expiration Date: 3/rD <br /> Phone: ( l2-qoi ,-q4a^7 (office) (cell) <br /> Mailing.Address: gusa- t53�"PiatP City: , 4- ZIP: <br /> Contact Person: Dict' 4hnet Applicant is: '.n rac o / Homeowner (Circle One) <br /> Email and/or Fax: Jc', greoncivt (2 atc.fiSi.coni <br /> PROPERTY OWNER INFORMATION: <br /> Name: GGif, (p/-45e,ieD9 <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1. Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal & I <br /> Water Supply <br /> ❑ New Construction <br /> ❑ Single Family with {a Residence <br /> ❑Addition attached garage ❑ Garage/Accessory <br /> ❑ Accessory Building i Single Family with El Deck <br /> Bldg. ❑ Public Sewer <br /> ❑ Relocation detached garage ❑ Office/Commercial <br /> 0 Private Sewer <br /> ❑ Other: (specify) <br /> ❑ Multiple Family/Condo ❑Warehouse <br /> El Public El Storage El Public Water <br /> "Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review& permits. El Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) El Other: (specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.org <br /> Estimated Construction Valuation (excluding land) $ i .K6Et, <br /> Last Updated: 9/29/2009 <br /> - 17- <br />