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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> 0Mailing Address: Permit number: <br /> PO Box 66 - j>d (p <br /> 'gv ,� <br /> 0 '. Crystal Bay, MN 55323-0066 Date received: Jzaz�lln <br /> Street Address:' Received by: �'Yl <br /> 2750 Kelley Parkway � <br /> a Plan review fee: 02 ��" D�/z <br /> t`�xEsxo4� Orono, MN 55356 <br /> TotalFeeo� f <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us r <br /> This application form must be completed in full and all required informatio must be submitted. <br /> GENERAL INFORMATION: Incomplete applications will be returned. (Please print) <br /> Job Site Address: t4(p5S 70A.)ky- U 1 CL L*AJ C <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �&No <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/APPLICANT INFORMATION: <br /> Name: C • C N <br /> State License# 6 31 Expiration Date: 313 1 Z Of I <br /> Phone: qSZ• y 4 - 43$O (office) S L —C4 b4 -036 Z (cell) <br /> Mailing Address: 7616 6%,T0.V104 pW M AJ utZ. p%)T City: ZIP: <br /> Contact Person: Applicant is: on rac o / Homeowner (Circle One) <br /> Email and/or Fax: stpe -e-k <br /> PROPERTY OWNER INFORMATION: <br /> Name: A}wg _1® 4- RdLC_ L 1 C.uIPS 1 <br /> Phone (day): 4-5-4-- 76 y <br /> Address: 172°61 76 pe-nm ouoerw- City:/MaLple (aro0e_ZIP: !95'31 <br /> Email and/or Fax p.*,& ,e\o ,rc Q• <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 /> X New ConstructionWater Supply <br /> Single Family with ,Residence <br /> ❑Addition attached garage ❑ Garage/Accessory Bldg. Public Sewer <br /> El Accessory Building El Single Family with El Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial <br /> El Other: (specify) El Private Sewer <br /> ❑ Multiple Family/Condo El <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) $ �(����. <br /> Last Updated: 9/29/2009 <br /> - 17- <br />