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CITY OF ORONO 410) <br /> BUILDING PERMIT APPLICATION <br /> FOR NEW STRUCTURES OR ADDITIONS <br /> q,. Mailing Address: Permit number: .2D 011.57 <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address:' Received by: <br /> 2750 Kelley tiF <br /> fi G� Y Parkwa Y Plan review fee: <br /> e Orono,MN 55356 <br /> k�'st[o �' 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: 1070 -rqmKAwA RD <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ YesNo <br /> If yes,a special event permit Is required with Police Department and City Council approval 60 days prior to the event. Shuttle bservice viii <br /> us <br /> required unless applicant demonstrates sufrclent on-site parking Is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: GMOLIQ <br /> State License# C 3Zyr Expiration Date: 11ZP1.5 <br /> Phone: cell office / .13S.80ZG <br /> Mailing Address: /5050 2 E N Cit u? ZIP: 55Ky <br /> Contact Person: At-QW-1 6L*s NkN-r Applicant is: ontrac o>/ Homeowner (circle one) <br /> Email and/or Fax: a c c <br /> Qy <br /> PROPERTY OWNER INFORMATION: <br /> Name: RAY 4- LPu%CCA. WA/..&.AN DEiZ <br /> Phone(day): <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: Descri tion ofproject: <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> , New Construction WSingle Family with Residence <br /> El Addition attached garage Garage/Accessory Bldg. ]W 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 also require ❑Commercial ❑Other(specify) <br /> MCWD review&permits. ❑Industrial I Private Well <br /> Minnehahe 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) a f 87Z. , �D 2- <br />