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Building Permit Application # Z`0MC) W <br /> DENIED City of Orono <br /> Reasons) for denial:iRM81ding Permit Application <br /> rvew Structures or Additions <br /> ail Address: Permit number: ) <br /> Sta 1 �Date: ox 66 <br /> \ Crystal Bay, MN 55323-0066 Date received: <br /> 0 <br /> 1 4 <br /> Street Address: <br /> Received by: <br /> 2750 Kelley Parkway Plan review fee: MJ, <br /> ykESHo4 Orono, MN 55356 ,C;�_ <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: J '/—z7(y-0 0e <br /> Will this be a Parade of Homes, Remodelers Showcase Home or 6ther Display Home? ❑ Yes Flo <br /> If yes,a special event permit 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 sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP ICANT INFORMATION: <br /> Name: r a. C - �.� <br /> State License# !b I y 10 Expiration Date: �+ <br /> Phone: Q t 0 '1 q H 7 office (cell) <br /> Mailing Address: ;acr `1 /S3 ,-'' ce City: ZIP: 'Lary/Y <br /> Contact Person: _f®e r,Ph.mac,.� Applicant is: Contractor 1 Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION- <br /> Name: <br /> Phone (day): i:3 — &70 SZ Z� <br /> Address: City: ZIP: <br /> Email and/or Fax <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 /> 17­1New Construction ElSingle 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) $ PRO00 <br /> Last Updated: 9/29/2009 <br /> - 17- <br />