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City of Orono <br /> fti.ld-Ing Permit Application__ <br /> for New Structures or Additions <br /> Mailing Address: <br /> 0. PO Box 66 Permit number: <br /> Q 0 Crystal Bay, MN 55323-0066 Date received: Jr <br /> a. Street Address:' Received by: <br /> ��t r Gtiti 2750 Kelley ParkwayPlan review fee: O / <br /> 9 4w Orono, MN 55356 <br /> kEsxo <br /> Main: 952-249-4600 Fax: 952-249-4616 wwvv.ci.orono.mn.us Total Fee: coo// -DOqt 75 <br /> This application form must be completed in full and all required information must be sub Itted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: n <br /> Job Site Address: �a O �,;a'k� Ci yza <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: L�c y F3�^os 4�rr1 c <br /> State License# Expiration Date: 3–,a 1 is <br /> Phone: Q _ �y office cell <br /> Mailing Address: d Cit . e V ZIP: <br /> Contact Person: �„�'c L.Qh r,,-sQt- Applicant is: ontract / Homeowner (Circle one) <br /> Email and/or Fax: on c c� 1 6� Goan <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: —[2 i� >�� City' ©(�-�rZIP: <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: LQcv } OS <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> ❑New Construction ® Single Family with 19 Residence <br /> $[Addition attached garage ❑ Garage/Accessory Bldg. ® Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑Relocation detached garage <br /> Other: (specify) g g ❑ Office/Commercial El Private Sewer <br /> ❑ Multiple Family/Condo ❑Warehouse <br /> F`- ❑ 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) $ 40`CXDQ <br /> Last Updated: 9/29/2009 <br /> - 17- <br />