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h I <br /> A.5 <br /> City of Orono .-d <br /> Building Permit Application or? 40/p <br /> for New Structures or Additions <br /> Mailing Address: Permit number- o2 e>1 o2 -DOlofj 7 <br /> O PO Box 66 �'/ _ <br /> Crystal Bay,MN 55323-0066 Date received: d /Z <br /> Street Address:' Received by: <br /> 2750 Kelley Parkway Plan review fee: /O/B 3c1 CG <br /> Orono, MN 55356 ,?p/d _D O 76 <br /> Total Fee: <br /> Main: 952-249-4600 Fax' 952-249-4616 www.a Orono-minus <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be retumed. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ,3LZ 7bnK11-LV c)ad oletno M N 555 9E;7, <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? 0 Yes No <br /> K yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event Shutda bus service will be <br /> required unless applicant demonstrates sufficienton-site parking is available Non-permitted events will not be allowed <br /> CONTRACTOR/APPLIC�NT INFORMATION: <br /> Name: JeAstri I- xmsk Zrn e- <br /> State License# t Expiration Date: 3-is 1 -x113 <br /> Phone: 4 62 -4-7-S -y S (office) (cell) <br /> Mailing Address: /2z.s City: Nr ZIP: $'S <br /> Contact Person: Applicant is: Cg2ntactor / Homeowner (circb one) <br /> Email and/or Fax: i IVA tQ,tiSs ni�trr]�S....Qom^ — <br /> PROPERTY OWNER INFORMATION: <br /> Name: rY10 J+ha. j'YIOt.C/�r((QJl <br /> Phone(day): Q R -4-73 - 7 <br /> Address_ .L_,_)a+_ aLot.- City: ZIP: S'S36-zo <br /> Email and/or Fax <br /> ARCHITECT/ENG EER INFORMATION: <br /> Name: X DS 't - RC,A <br /> Y <br /> Phone(day): / - /O - 9 .7 <br /> Address: SF 7 Cit : ZIP: 5'5 <br /> Email and/or Fax: `6h,-/ien,O Can>rca.��.nr <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal 3 <br /> Water Supply <br /> ❑New Construction qq Single Family with ❑Residence <br /> ❑Addition attached garage ❑Garage/Accessory Bldg. ❑Public Sewer <br /> ❑Accessory Building ❑ Single Family with §kDeck <br /> ❑ Relocation detached garage EJ Office/Commercial ❑Private Sewer <br /> Other: (specify) fat. _ aoy',�M ❑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,minnebehagreek-m <br /> Estimated Construction Valuation (excluding land) $ l�5� <br />