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` City of Orono <br /> Building pp Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: <br /> 0PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 0-46-13 <br /> Received b 1�6s <br /> Street Address:' <br /> y <br /> �cn rt xv o` 2750 Kelley Parkway Plan review fee: 373. 2L <br /> Orono, MN 55356 <br /> ESKo, c;2 o 0 -o o a a i <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: S T0ty t,0WA Qa <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> !f 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: <br /> State License# Z Expiration Date: 3/3t <br /> Phone: q lZ 7 SLID -7150 (office) �7- (cegl) <br /> Mailing Address: 7o1,1-7 )6u-7-e—+1 Rl\)A City: Qq 011'S ZIP: SS�12 <br /> Contact Person: `�_ g-l� Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: o\rIAAI- (z-,)a U 1 ;j AJ , G onn <br /> PROPERTY OWNER INFORMATION: <br /> Name: G[ArI's <br /> Phone (day): <br /> Address: �c��S �i,n�y4�c� ��] City: (kQ8z6 ZIP: 5631 <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: �/,F?Kvl.��e� L!iA) Orbv>° <br /> Phone(day): <br /> Address: G Ie,- S771 City: Z.4, ZIP: 3� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: A,,00M On �yJd r/oo IF- <br /> 1. Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> Water Supply <br /> ElNew Construction ElSingle Family with 'S Residence <br /> ❑Addition attached garage ❑ Garage/Accessory Bldg. ❑ Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial <br /> Other: (specify) P.NUo(-,e_I ❑ Multiple Family/Condo El Private Sewer <br /> p y ❑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) <br />