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. , � � �s <br /> City of Orono '�- � <br /> Building Permit Application � <br /> for New Structures or Additions <br /> Mailing Address: <br /> ��j,0� PO Box 66 Permit number: ab j 3 "�0 J Z <br /> r�� , � Crystal Bay, MN 55323-0066 Date received: Z�Z( ��3 <br /> � �# <br /> II ,�r° � � Received by: <br /> 1,� t�� �_.� a, , Street Address: <br /> \�',�, ���;��p„ Gti� 2750 Kelley Parkway Plan review fee: a2 5 7 I . B � <br /> �l9 `+� �?'�"�� Orono, MN 55356 ao�3 - �0 �ZS <br /> kE9H�g' <br /> �--=-� Total Fee:, <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �,( ?� ��y , ' � ���' 3lcE.,�f� <br /> This application form must be completed in full and all required informa ion must be submitt . <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: �3 6 U � � //I Y�-Q , <br /> Job Site Address: /�r <br /> Will this be a Parade of Homes, Remodelers Showcase Home or 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 will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP ICA T INFORMATION: f � <br /> Name: �,�,�,�0 a/ �'v KJ S'��QuU'c�nJ <br /> State License# a Expiration Date: / / <br /> Phone: - office cell <br /> MailingAddress: u��C a�e Cit : p q ZIP:$$,�03 <br /> Contact Person: D u,(S o n� Applicant is: Cont�r / Homeowner (Circle One) <br /> Email and/or Fax: t�u, u,l so N 7 Co�rn Ch`S�� u�f <br /> PROPERTY OWNER INFORMATION: n <br /> Name: �e u,N � �i9�p� l9-P�j a� <br /> Phone (day): a (� j D�a <br /> Address: Jgp �R � LQ.hJP lv Cit : �I �OU,�� ZIP:cS.s�l�{7 <br /> Email and/or Fax M� �2q Q �rn q,nl � Q�(�1,6J , C 0/Yn <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& <br /> Water Supply <br /> �New Construction �Single Family with �Residence <br /> Addition attached garage ❑ Garage/Accessory Bldg. 0 Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial �Private Sewer <br /> ❑ Other. (specify) ❑ Multiple Family/Condo ❑Warehouse ' <br /> ❑ Public ❑ Storage ❑ Public Water <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 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) $ �� (jU(� , <br />