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<br /> �� Cit of Orono � l ' �
<br /> Y
<br /> Building Permit Application
<br /> for New Structures or Additions
<br /> — Mailin�,,q�lrl�e��; Permitnumper. p�DU/ — QU7�,�i�7
<br /> O�,L,�,j�� PO Box 66
<br /> � \� Crystal Bay, MN 55323-0066 Date received: /U 09 O
<br /> '�ii.:3 � 1
<br /> � �'�`�-�'^;�, a,� Street Address:' Received by: �"Y��
<br /> x'� �, � �� �� 2750 Kelley Parkway Plan eview fee: � �, $9
<br /> L�kE3H 4� Orono, MN 55356 �OC� g — �O �� �
<br /> - Total 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: �—�+ �, g��+c.l= 3 5u �:�G�s �jU �� � �,�jr��/.'
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ ❑ No
<br /> /f yes, a specia/event permit is required with Po/ice Department and City Council approval 60 days prior to the event. Shutt/e bus service wil/be
<br /> required unless applicant demonstrafes sufficient on-site parking is available. Non-permitted events will nof be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATIO`N:
<br /> N a m e: �-�.�.er � �> P(�21 N.i.^ �--,--�-- ( ��o..� �/�or�..o� / L/`;�' �' `�C�t'so�>
<br /> State License# "3�1�Z-\ Expiration Date: 3 - 3�, Z�t o
<br /> Phone: �C `i SZ.. 413- 3 office ca�z 3�Z�' - £'�'�"� (cell)
<br /> Mailing Address: ��40 �;v�,,e}�,.�� [��,A,. Cit : -��-�, ZIP: 5 j 3`��
<br /> Contact Person: __'"j"�� p��'�,,,,,.�,,_ Applicant is: ontract r / Homeowner (Circle One)
<br /> Email and/or Fax: -j-�,� c� S ����r� �orn�e�w��..�.. co�� SZ l -- ZD8
<br /> PROPERTY OWiVER INFORMATION:
<br /> Name: �Tor� �� C�i�•y-, Sw�� }-t�
<br /> Phone (day): (°�52..) ¢4"1 - 3�5"1
<br /> Address: Z�o1 ����{-�..��c,.�.y �;,,� City: O�•ti� ZIP:
<br /> Email and/or Fax �
<br /> ARCHITECT/ ENGIN i2 INFORMATION:
<br /> Name: ���e nn� �C �,.�
<br /> Phone (day): ��52..) 4����- S43�
<br /> Address: 1Q�34o r,h; ,,-�a (3�J�� , Cit : w ���.2 ZIP: S)3\1
<br /> Email and/or Fax: �.,,2�. a .Q,,.e� �c,o i�,,,.� , cow. � Z 41`3-S'LD€;
<br /> PROJECT INFORMATION:
<br /> 1. Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal 8�
<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 ❑ Private Sewer
<br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑Warehouse
<br /> ❑ Public ❑ Storage �Public Water
<br /> "`*Any earth movement may require ❑ Commercial ❑ Other(specify)
<br /> MCWD review&permits. ❑ Industrial ❑ Private Well
<br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (SpeCify)
<br /> 18202 Minnetonka Blvd
<br /> Deephaven, MN 55391
<br /> Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> www.minnehahacreek.or
<br /> Estimated Construction Valuation (excluding land) $ t ,4'S'�j � 4 C'�
<br /> Last Updated: 9/29/2009
<br /> - 17-
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