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&X- <br /> tq <br /> City of Orono <br /> Building pp Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: <br /> PO Box 66 <br /> Q ` Crystal Bay, MN 55323-0066 Date received: —/ --1 <br /> Street Address:' Received by: Wj �- <br /> / 2750 Kelley Parkway Plan review fee: 7 3 3 <br /> t�F� Orono,MN 55356 <br /> k t H oR� Main: 952-259-4600 Total IF <br /> Fax: 952-249-4616 . 1� <br /> This application form must be completed in full and all required information must be submitte <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: -�-�^ <br /> Job Site Address: 70 e; ,eoolx ko. LeA✓G 2-xAe&7, <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: � S <br /> State License# S Expiration Date: 319" <br /> Phone: cell • office S • 35,T <br /> Mailing Address: 2 � t.0 03ao City: S •LOl4K ek ZIP: SO y <br /> Contact Person: ^VC!% OA Z R6V!f Applicant is: o ac or / Homeowner (circle One) <br /> Email and/or Fax: Cora bb#f if TCM11ADdr?LCdP7J019A119S.COM <br /> PROPERTY OWNER INFORMATION: <br /> Name: frWCy J;6)t6A,1r SyIROSoN <br /> Phone (day): 6I4 • 94b • Q76 2 <br /> Address: 76o "A-DNA WA 12n City.ZcAIA LA$a ZIP: <53 Ski <br /> Email and/or Fax /VAA/C y& AM 00 etz • t'1/ <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: .5'Ay►lar �4 S C649MA C-f s14i4,S C649MA C-f&2. <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> XNew Construction Single Family with WResidence <br /> ❑Addition attached garage Ef Garage/Accessory Bldg. Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑Deck <br /> ❑Relocation detached garage ❑Office/Commercial <br /> El Other: (specify) El Private Sewer <br /> ( p fy) ❑Multiple Family/Condo ❑Warehouse <br /> ❑Public ❑Storage ❑Public Water <br /> **Any earth movement may require ElCommercial ElOther(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.m innehahacreek.o <br /> Estimated Construction Valuation(excluding land) $ 400 GOO. <br /> Packet Last Updated: 04119/2013 <br /> Page 22 of 23 <br />