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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: <br /> Q PO Box 66 Permit number: <br /> � �Q Crystal Bay, MN 55323-0066 Date received: Cj ''� <br /> StreetAddress:' R ved by: � <br /> y ,� 2750 Kelley Parkway �� � � <br /> `� �� Orono, MN 55356 � � I review fee: <br /> t�kf5 H O�� Main: 952-249-4600 <br /> Total Fee: <br /> Fax: 952-249�616 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: �jg 5 �QR.�r�Y� N,�� �2� p2�b ►'Y1r� 55�?1 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> !f yes,a special event pe�mit 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 su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/AP L� ICANT INFORMATION: <br /> Name: ((�C.�rL �i� <br /> State License# Expiration Date: <br /> Phone: (cell) 520-4ba-'1'137 (office) �Cc3-q I�- Slo3$ <br /> Mailing Address: � ,� Ci : � Z�P: q � <br /> Contact Person: �']�(�yrt_ ��� Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: �(�y(�,�C� .��� �vpry, <br /> PROPERTY OWNER INFORMATION: <br /> Name: �Z�n �Z��� <br /> Phone(day): 5Z�- - O� -� �_ <br /> Address: q�j SQfLr-� �1u (� Ciry• ORc�r�c� ziP� 53�r i <br /> Email and/or Fax iZ�L��Q�-���rL � ��L, �� <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: ��Sr�tZ i��..i�Di��:C.-:5 �.�c". <br /> Phone(day): (��r�) 3'�5 - � 3 I �.5�.��L <br /> Address: �.��. 5�_<'cr�.:�� r}�x ,=1 � `� � -��U City' w�,:.��.�ir ZIP: 55� 4 <br /> Email and/orFax: ��t _• -��ifi - 5' '�C�, <br /> PROJECT INFORMATION: Descri tion of ro�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 ❑Public Sewer <br /> �Accessory Building ❑ Single Family with ❑Office/Commercial <br /> ❑Relocation detached garage ❑Residence <br /> ❑Other: (specify) ❑Multi le Famil /Condo ❑Private Sewer <br /> P y ❑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) �Other:(speCify) ❑Other(specify) <br /> 15320 Minnetonka Blvd �yJey 13(r.ILDlr�s � ,F}ppL�C�-g(�— <br /> Minnetonka,MN 55345 <br /> Phone: 952�471-0590 N� v3�kt"�rt o�2 <br /> Fax: 952-471-0682 fj� C�_ <br /> www.minnehahacreek.or � ��L ��,-� <br /> Estimated Construction Valuation (excluding land) $ '�j, O`�p , G� <br /> g���== ��l W�%�' .\ <br /> Packet Last Updated: August 2015 �����C:� �� Q� J <br /> Page 21 <br />