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, , ' '✓' �5�;;,, �Szszrr���f <br /> �' �SCro Lu �cJ- <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: - ,+ " <br /> ��Q A,\ PO Box 66 Permit number: <br /> �VQ , Crystal Bay, MN 55323-0066 Date received: " 5 �� <br /> I Street Address:' �y y� R�,ceived by: <br /> y�� ��;' 2750 Kelley Parkway ; -�"�'�'�-"� � � <br /> ` Orono, MN 55356 ����� I review fee: . �.0 <br /> 1 kE5 HO�` ... ._._._ <br /> / Main: 952-249-4600 Total Fee: '� ���� �^ <br /> � Fax: 952-249-4616 :�.::w�� c;����-��,e r,�:�� ��,�.� <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: 3q 5 �PW rLX� F-��� �2-r� D2� ��' 553�1 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> /f yes,a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/AP LICANT INFORMATION: <br /> Name: �i(,�`1 <br /> State License# Expiration Date: <br /> Phone: (ce��) 520 -�-�13� (office) �c�3-4 i�- 8�3� <br /> Mailing Address: $ r-� 1� Zr Cit : QQ,p ZIP: q � <br /> Contact Person: �ZpLtsrt rL�� Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: (�=��y(J�(„�(z�J� [�r1cl-.SL. ('�m <br /> PROPERTY OWNER INFORMATION: <br /> Name: IZ��iz IZi L��I <br /> Phone(day): 5'lc - 'G� -"l� I�� � <br /> Address � q�j �(Z,i� �}-1-1 t� �Z�� City: �(��,�-�v ZIP: ��j�j�' � <br /> Email and/or Fax +ZLt�`-1 i��-��� � �Y�Gt�L, C�,r^ri <br /> ARCHITECT!ENGINEER INFORMATION: <br /> Name: �.,.��riF;z ���,<<r.�,r C• ., l L.� <br /> Phone(daY)� ! 3zt.) 3'i 5 � �5> I ce-5�►�_�z <br /> Address: -�.�_l� ';t- < c�_. �� r�c:`t ,-�,l `� c-�t�1 C�ty� i'�Lt�p2�L' ZIP: 55 7�G <br /> Email and/or Fax: ;�e: ��r'S - 5 5� �. <br /> PROJECT INFORMATION: Description of ro�ect: c �/ ►� � ���`� � � <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal 8 <br /> --_._.._."�___------.,-._._., Water Supply <br /> ❑New Construction ❑Single Family with � �Accessory Bldg./Garage <br /> ❑Addition attached garage ----- <br /> Public Sewer <br /> �Accessory Building ❑ Single Family with ❑O�ce/Commercial <br /> ❑ Relocation detached garage ❑Residence ❑Private Sewer <br /> ❑Other:(specify) ❑Multiple Family/Condo ❑Retaining Wall(s) <br /> ❑Public 4-feet or greater ❑Public Water <br /> '*Any earth movement may require ❑Commercial ❑Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse ❑Private Well <br /> Minnehaha Creek Watershed District(MCWD) �f Other: (specify) ❑Other(specify) <br /> 15320 Minnetonka Blvd µ�[�D��-( I�IR.I LD�+'� t�� 'A PPU�A'B�-E - <br /> Minnetonka,MN 55345 <br /> Phone: 952�71-0590 N� ��L2 o�L <br /> Fax: 952-471-0682 ��� ��- <br /> www.minnehahacreek.or Y�C.C. (L`�l 13�-1� I"�'� <br /> Estimated Construction Valuation (excluding land) � ���� O�� , Gv <br /> ����'��== 1}.-�►W�ti'�` <br /> Packet Last Updated: August 2015 �L(,E'```-� �K� Q�"D J <br /> Page 21 <br />