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. ` Ci�y of �ro�� <br /> �uiidin� P�rr��t i4p���cation <br /> for �evv �tre�c�ur�s or �da�t���s <br /> Mailing Address: <br /> �o�j PO Box 66 Permit number: v�D/�7-U/l(p� <br /> Q Crystal Bay, MN 55323-0066 Date received: �-,�(�i�`--f�� <br /> StreetAddress:' Received by: j�� <br /> y� ��C' 2750 Kelley Parlcway � Plan review fee: <br /> �,�kEs�o�`�,L Orono, MN 55356 /1� �� <br /> Main: 952-249-4600 v"- Cj(�,� Totai Fee: ����� �9 <br /> Fax: 952-249-4616 wwu,�.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications wiil be returned. (P/ease print) <br /> GENERAL INFORMATION: _ __ <br /> �` � ' '' � . � � �-, � I.: _ � <br /> Job Site Address: � � . � ,- . -, , ` , �r , ,: � �-��_�_ � ,�J `�(,�1�.� �j 7/ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes - No <br /> /f yes,a specia/event pe�mit is required wkh Police Department and City Counci/approval 60 days prior to the event. Shutt/e bus service will be <br /> required unless applicant demonstrates sufficient on-s/te parking is evailab/e. Non�ermitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License # Expiration Date: _ <br /> Phone: cell (office) <br /> Mailing Address: Cit : Z�p: <br /> Contact Person: Applicant is: Contractor / Homeowner <br /> Email and/or Fax: fc�►�ie o�e� <br /> PROPERTY OWNER INFORMATION: � /��J <br /> Name: -/'✓��L�%��Z ���-��`1�-- <br /> Phone(day): � '7� <br /> Address: l ` _'L� �i -' � Ci :�G'%"� � ZIP: � ���/ <br /> Email and/or Fax -`� y ; ,.— ��s�._e� r- `7 < :C�,, <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: Cit : ZIP: <br /> Email and/or Fax: <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone{day): <br /> Address: Cit : Z�p. <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Descri tion of ro'ect: <br /> 1.Type of ProJect 2. Proposed Use 3. Structure T e <br /> Yp 4.Sewage Disposal& <br /> ❑ New Construction Water Supply <br /> ❑ Single Family with ❑Accessory Bldg./Garage <br /> ❑Addition attached garage ❑ Deck <br /> ❑Accessory Building ❑ Sin le Famil with ❑ Public Sewer <br /> � Relocation g Y ❑ Office/Commercial <br /> detached garage ❑ Residence Q Septic <br /> ��Other.(specify) �li�'I Sh� /�"j)�_. � 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 8 permits. ❑ Industrial ❑Warehouse <br /> Minnehaha Creek Watershed District(MCWD) ❑ PubliC Water <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 ��(�, er. (SpeCi ) � ; O�he�(speCify <br /> Phone: 952-471-0590 / Fax: 952-471-0682 f""' —/ C� '" '— -- �"����"� ❑ Private Well <br /> www.minnehahacreelc.ora <br /> Estimated Construction Valuation (excluding land) $ -,� ; �:Z �, <br /> � <br /> Packet Last Updated: January 2016 <br /> Pa.qe 21 <br />