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City of Orono <br /> Blfng Permit Application - <br /> for New Structures or Additions s z <br /> Mailing Address: <br /> 0PO Box 66 Permit number: 0101 D-d// <br /> 'Qv .� <br /> Q Crystal Bay, MN 55323-0066 Date received: <br /> s <br /> •� �, Street Address:' Received by: <br /> ��nt yn �Gti 2750 Kelley Parkway Plan review fee: <br /> 9�ESS0 Orono, MN 55356 CA0/O-oz/ <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: app a-i—,,,Q�( Cjr,pro "n S5356 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes XL 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: Rn=. Homez. <br /> State License# C_5 S S_ZT Expiration Date: frkXyr,6 �(a <br /> Phone: _ L(— office cell <br /> Mailing Address: City: ne a ZIP: SS 345 <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: Tar k ag JP_cy rr3s . Ccam <br /> PROPERTY OWNER INFORMATION: <br /> Name: She((a. A,8amS <br /> Phone (day): <br /> Address: c�Tvrc City'(Drt>/11D ZIP' G;,539(— <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: Saxne pcg C nor � <br /> Phone (day): - <br /> Address: City: Zi P' <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal & <br /> ❑ New ConstructionWater Supply <br /> ® Single Family with Residence <br /> Addition attached garage ❑ Garage/Accesso <br /> ❑Accessory Building El Single Family with El Deck <br /> Accessory Bldg. © Public Sewer <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 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) $ —4d.c<)n <br /> Last Updated: 9/29/2009 <br /> - 17- <br />