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�lfy O'� �COt10 rtt�t�vtu <br /> � � E3�ildinc� PermE� �4pp�ication �uN �� 0 20�� <br /> for �evor S�r�c�ures or �dditior�s CITYOFORONO <br /> Mailing Address: <br /> QA� PO Box 66 Permit number: �QJ `� ���p7� <br /> � j Vo Crystal Bay, MN 55323-0066 Date received: ��—) 7 <br /> Street Address:' Received by: � <br /> � ,� 2750 Kelley Parlcway �0 ��a�� <br /> y�. Plan revie e: /`7 <br /> G� Orono, MN 55356 <br /> �'XfSH��� Main: 952-249-4600 Total Fee: t5� �� <br /> Fax: 952-249-4616 ww�n�.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: ��� �f��GS V� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes,a specia/event permit is required with Police Deparfinent and City Council approva160 days prior to the event. Shutt/e bus service will be <br /> required unless applicant demonsfrates sufficient on-site parking is availab/e. Non-permitted events wiU not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �;V l�l-kV lElt�1,��;�L'j� -- �A-k��j� �'11�1�0l� <br /> State License # Expiration Date: <br /> Phone: cell � 2 Z.`6�. - `�' office _ %� a p' - p p n <br /> Mailing Address: � � V p Cit : ' �,z L, Z�p: r-��� <br /> Contact Person: — � Applicant is: ontractg�/ Homeowner (CircleOne) <br /> Email and/or Fax: � �� � . ,�,� -- <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��``-�� ,� � <br /> Phone (day): Z. �'p -. S 1 2 <br /> Address: ` � � -' Cit : /t�l� ZIP: S �-J�� <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: Z�p� <br /> Email and/or Fax: <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: City: Z�p• <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of pro'ect: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal 8 <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 /> g y ❑ Office/Commercial <br /> ',�❑ elocation detached garage ❑ Residence ❑ Septic <br /> Other:(specify) ������ ❑ Multiple Family/Condo ❑ Retaining Wall(s) (Compliance certificate <br /> ����.5 ❑ Public 4-feet or greater may be required) <br /> **Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) ❑ Other(speCify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 ❑ Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.m innehahacreek_orq <br /> Estimated Construction Valuation (excluding land) $ �"� n0� <br /> Packet Last Updated: January 2016 <br /> —ri--- <br /> Pa.qe 21 <br />