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<br /> > ��l�b � �
<br /> City of Orono �� �
<br /> �
<br /> Building Permit Appiication
<br /> for New Structures or Additions
<br /> Mailing Address: Permit number: %b b//.3�5
<br /> �,�,� PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: /
<br /> �����`"�' � Received b
<br /> a �'"t�-a�-��; a StreetAddress:' y�
<br /> �'��c,t �'o-�'.� Gti`� 2750 Kelley Parkway Plan review f�
<br /> .�k�� fP� g,� Orono, MN 55356
<br /> Esxo �.��
<br /> Tofal Fee.
<br /> Main: 952-249-4600 Fax: 952-249-4616 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: -,� ��5 ��;,-c.;, c,f, ��-'c..y
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ,�'No
<br /> !f yes, a special event permit rs 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/APPLICANT INFORMATION:
<br /> Name: �c..,-v �f[i.Z:,t .'"
<br /> State License# �— Expiration Date:
<br /> Phone: (1�-�=�/(��7 �}— (cell)
<br /> Mailing Address: y �-�- �,�, Q_ v�,� . Cit ;��� - ; ��'a,:,r ZIP: c-s:�S�,
<br /> Contact Person: �Q,,; y. �,,,,,z;�-r' Applicant is: Contra tor / Homeown �c�r�ie o�e�
<br /> Email and/or Fax: -I-�.�,�-r�c,- -�-n -��,�.�;� : r�,��.ti-. �a.; i,��-�/7�_ yr����_
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: Cca.'c'� r�rc,,7-; e,r'
<br /> Phone (day): �-� � ;�.,- �, i' - yi� I '�
<br /> Address: ��� ��,,..;,,-,- � wG,Y .� r'- �'-�-�., City�..�,��.�,i%�i�..;,- ZIP� ��.;��
<br /> Email and/or Fax ��,,�' -��? - � �a_. �:�a� " .��„4�.'l - - P =�r��r � i r ow,.
<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. ❑ Public Sewer
<br /> �Accessory Building ❑ Single Family with ❑ Deck
<br /> ❑ Relocation detached garage ❑ Office/Commercial
<br /> ❑ Other: s eci ❑ Private Sewer
<br /> ( p fy) ❑ Multiple Family/Condo ❑Warehouse
<br /> ❑ Public � Storage ❑ Public Water
<br /> "`Any earth movement may require ❑ Commercial ❑ Other(specify)
<br /> MCWD review 8�permits. ❑ Industrial ❑ Private Well
<br /> Minnehaha Creek Watershed District(MCWD) � Other: (speCify)
<br /> 18202 Minnetonka Blvd <'°
<br /> Deephaven, MN 55391
<br /> G:,.r ..(�.�•. �r.�., _
<br /> Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> www.minnehahacreek.or
<br /> Estimated Construction Valuation (excluding land) $ ;�p ''
<br /> Last Updated: 9/29/2009
<br /> - 17-
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